Comfort Theory: A Framework for Pain Management Nursing Practice

Overall Objectives

Describe Comfort Theory and its

application to pain management nursing

practice

Discuss the application of Comfort Theory

in clinical practice

Individual

Select Populations and Practice Settings

Health Care Systems

Memorable Nurse

“The unique function of the nurse is

to assist the individual, sick or well,

in the performance of those

“…what nursing has to

activities contributing to health or its

do…is to put the patient in

recovery

(or to peaceful death)

that

the best condition for

he would perform unaided if he had

nature to act upon him.”

the necessary strength, will or

knowledge. And to do this in such a

Florence Nightingale

way as to help him gain

Notes on Nursing

1859

independence as rapidly as

possible”

(19 58 )

Virginia Henderson’s definition of nursing

A historical perspective of comfort

Memorable Nurse

and nursing care:

Describe a nurse

1900-1922- a central focus and moral imperative

Care with kindness

colleagues that

1930-1959- a strategy for achieving aspects of nursing

Time and touch that

care

delivers exceptional

fostered healing

nursing care

1960-1989- became a minor goal

Listened

Ph ysica l  asp ect s  of   care  w ere  d omi nat e

Describe what a

Emo t ion al  co mf ort  b eca me  in crea sin gl y  i mpo rta nt

nurse did for your

Respect

1990-2006-Comfort Theory

loved one

Special attention-

Ch il dbi rt h  pa in

Describe what a

individualized

En d  of   lif e  a nd  p all ia ti ve  care

nurse did that

Pa in  Ma nag em ent

comforted a patient

?  D isco mfo rt  a   pot e nt ial  N ursi ng  D ia gn osis

?  C omf ort - a  pro po sed  N I C

Comfort Theory:

State of affairs******

It makes sense to me

Patients with pain scores of 10/10 despite

increases in medication

Provides a holistic approach

Patients with complex medical care-

Supports clinical decision making

experiencing loss and suffering

Helps explain nursing care

Expectations that pain scores would be “0”

Colleagues understand comfort

Nursing staff not knowing what to do if

Patients understand it and parents

medication did not help

can be an integral part of care

Personal feelings of frustration and

Framework for my practice

inability to make a difference

What is Comfort ?

Comfort is a Useful Concept

A blanket or a favorite sweater

It is important:

A family member close by

…for patients working to return to former

Music: a lullaby or rock

functional levels

Human touch-rocking

A call or visit from a friend

…for for patients going through strenuous

A prayer or quiet moment

therapies

Medication to ease the pain

…for those who want to die in a dignified

way

Comfort is defined by the individual

Kolcaba’s Comfor

Theory

Comfort is:

Human needs are addressed

Individualized - holistic

Relief: the state of having a discomfort

Enhanced feelings of well being

mitigated or alleviated

A sense of being strengthened

Ease: the absence of specific discomfort

Provides a framework for care

Transcendence: the ability to “rise

above” discomforts when they can not

Is not “comfort care orders” for

be eradicated or avoided

end of life

Comfort Theory and Practice

Comfort Care

Holistic Approach

• All Patients

• Four General Contexts

• Physical

• Distress: 4 Contexts

• Environment

• Sociocultural

• Psychospiritual

• Comfort Interventions

• Types of Care

• Patient Outcomes

• Technical

• Coaching

• Comforting

• Optimum Function Peaceful Death

• Contexts of Comfort

• Contexts of Comfort

• Physical-pertaining to

• Psychospiritual-pertaining

• Environmental- the

• Sociocultural-

• bodily sensations and

• to internal awareness of

• external background of

• interpersonal, family and

• homeostasis

• self, esteem, sexuality,

• human experience

• societal relationships,

• meaning in one’s life

• family traditions, rituals

• Pain  relief

• Temperature

• Regular  bowel  function

• Maintain in gimp roving  self -

• Noise

• Ca ring   at titude

• esteem

• Fluid/ electrolyte  balan ce

• Color

• Cont inuity  of   care

• Enhancing  in dependence

• Adequ at e  oxygen

• Ligh t

• Informa ti on  and  edu cat io n

• saturat ion

• Increasin grela xatio n

• Views  from  the   window

• Enhancing   familyand  friend

• Turning   and   posi t ion in g

• Accommo dating  rligio us

• sup po rt

• Acce ss  to   nat u re

• practices

• Cultural  customs

Types of Care: Technical

Types of Care: Coaching

Maintain homeostasis)

Relieve anxiety and plan for recovery)

Monitoring & managing pain, nausea,

Provide reassurance and information

dyspnea, etc.

Instill hope, listen

Preventing complications

Administering medications

Help plan for optimizing health

Observing for side effects

Encourage

Comfort Theory-Patient Care

Types of Care: Comforting

A Case Study

Unexpected things)

16 yr female with IRB, partial colectomy and

take down ileostomy, multiple flares for three

Feel cared for and strengthened

months. Weight gain with prednisone

-Targets transcendence

Cramping abdominal pain (4/10)   Fentanyl

- Environment: music, art

patch 75 mcg/hr, PRN Oxycodone 15 mg PO,

- Massage, holding a hand

Lorazepam and Hydromorphone IV

School only 2 days in past 4 months

- Encouragement

History of depression, anxiety, suicidal ideation-

- Reminiscence, tranquility

on Lexapro

- Presence and memorable connections

Difficulty sleeping: now and prior to admission

A Case Study..

cont

PCA Hydromorphone

Family lives 4 hrs away; mom at home

Surgery: Total colectomy with ileostomy

with siblings, dad at hospital

Bowel perforation and wound dehiscence.

Supportive church family- uncle lives close

Painful wound exploration at bedside

to hospital

(10+/10): 4 days postop

Finances are “tight”

Three wounds- Dressing changes 3x day-

Loves music, history; does not like to be

anxiety and pain (10/10) required

touched or massaged

ketamine

Uses deep breathing at times

Wound vac applied to 1 of the 3 wounds

Comfort: Individual Patient

Physical

Psychospiritual

Environmental

Sociocultural

Self   esteem,  self    concept ,

Temperature,   light ,  sound,   odor,

Interpe rsonal ,  fami ly,   societal

Bodily  sensations  &  homeo stasis

sexuality,  meaning  in  life ,  &

color,  furniture ,  land scape  &

relationships,  finances,

Hydromor phone  P C A

spiritualit y

other  factors in  the  background

teaching,  traditions,  rituals ,  &

Methadone

of  the   human  ex perience

religious  practices

Deep breathing

Klonazepam  and  ambien

Music

Dadspend  the night

I m agery

Skincar e

Quiet

Connect  wit h friends / school

Child  lifereferral - dressing

Healing touch- -Mom

change

Routine  for   sleep

Financial support - meals

Coaching

Chaplin  referral

Comfort Theory:

Comfort Theory: Patient Units

Specific Populations

Identify Champions and Opinion Leaders

Alzheimer's

Staff involvement

Hospice

Compatibility with expectations

Postanesthesia Nursing

Staff Education- theory & leadership skills

Women and child birth

Quality Improvement Projects

Pediatrics

Chart audits

Ambulatory Care

Patient satisfaction survey

Comfort Theory: Systems

Comfort Theory: Patient Units

Dimensions of care related to consumer

satisfaction

Integrate theory into nursing practice

Respect me as person

Ask patients/families what you can do to

make them comfortable

Co-ordinate care

Assess and provide comfort – 4 contexts

Give predictive information

Teach families about comfort

Provide comfort and pain relief

Clinical discussions

Relieve my fears

Communication-shift report

Involve my family/friends

Communicate with colleagues: bulletin

Think of me as a person on a continuum of

board, clinical discussions and care plans

life---not an episode

Change and Diffusion

Lead Team = Champions

Develop knowledge and skill with

Start with a structure and process

comfort theory

Connect and communicate

Communication and feedback

Design practice: holistic-patient focus

Plan and direct

Integrate comfort into practice

Changes

Wide representation - practice settings

Policies & Procedures

Improve patient outcomes- measure

Develop leadership skills

Help remove barriers

Comfort Survey- Web based

Comfort Theory: Systems

Caring for patients begins and ends

Comfort Survey- Web based

Questions from Kolcaba survey

with comfort

Revised for children

Shortened

Each patient receives individualized, compassionate care

Testing and validation

in a culture that promotes well-being and comfort of

patients, families, and staff.

Paper and computer pilot

This practice will be characterized by: engagement, holism,

Data to be analyzed

listening, presence, kindness, patience, evidence,

respect, energy, empowerment, professionalism, and

collaboration.

Comfort for the Nurse

Physical

Break s

Sufferi ng

Comfort

Adequates taffre sources

Environmental

Fear

(organizational culture)

Pro fes si o na l is m

Pain

Open  Communication

Psychospiritual

Isolation    Loneliness

Encouragemen t

PalliativCar e

Anxiety

Managerial   support

Sociocultural

Nausea Dyspnea

Pain relief is a nurse sensitive patient outcome

Team  work

Collaboration

Hand Massage

Take Home Messages

Pain management can be approached from a

A 2-minute nursing

comfort perspective: physical, psychospiritual,

intervention

environmental, sociocultural

Easy to learn and do

Comfort Theory is useful in assessing and caring

Touch, connection

for patients in pain

relaxation, and support

Comfort Theory is a framework for nursing

Useful for patients and

colleagues

practice and can be applied to individual

practice, units and systems

Provides Comfort

Getting a new idea adopted even when it has obvious

advantages is often very difficult…Everett Rogers

“ M” Technique- Jane  Buckle,  RN

Comfort Theory and Care

Comfort Care

is a nursing art that entails the process of comforting actions performed by a nurse for a

patient. According to comfort theory, patients experience comfort needs in stressful health care situations.

Patients and their families/support groups meet some needs but other needs remain unmet. These needs

can be identified by a nurse who then implements comfort measures to meet the needs.  Enhanced

comfort readies the patient for subsequent healthy behaviors or a peaceful death. Comfort measures can

provide relief, help ease a distress or help support the patient to transcend the experience or condition.

Comfort Needs

are assessed in four contexts of patient’s experience:

•

Physical:

pertaining to bodily sensation and physiologic problems associated with medical

diagnosis

Psychospiritual:

pertaining to the internal awareness of self, including esteem, concept of

sexuality, and meaning in one’s life; this can also encompass one’s relationship to a higher

order or being

Environmental:

pertaining to the external background of human experience; encompasses

light noise, ambiance, color, temperature, and natural versus synthetic elements

Social:

pertaining to interpersonal, family and societal relationships

Types of Comfort Care

Technical:

Pain relief, positioning, monitoring

Coaching:

Relieve anxiety, provide information, instill hope, and plan for recovery

Comforting:

Things that make patients/families feel cared for, strengthened and connected

Relief Ease  Transcendence

Physical

-bodily sensations

Opioid for postop pain  Elevate leg for edema  Coaching for labor pain

and physiologic problems

Psychospiritual

-internal

Coaching and

Chaplain, deep

Support for giving

awareness, self-esteem,

encouraging-

breathing, guided

control and feeling safe.

spiritual relationship

imagery

Environmental

-light, noise,

Reposition due to

Distractions during a

Privacy and quiet for a

color, temperature

immobility

procedure, music

dying patient

Sociocultural

-interpersonal,

Information and

Interpreter, family

Religious practice or

family and society

education

visiting and presence

rituals

Comfort

by S.D. Lawrence (student nurse)

Comfort may be a blanket or a breeze,

Some ointment here to soothe my knees,

A listening ear to hear my woes,

A pair of footies to warm my toes,

A PRN medication to ease my pain,

Someone to reassure me once again,

A call from my doctor, or even a friend,

A rabbi or priest as my life nears the end.

Comfort is what ever I perceived it to be

A necessary thing defined “only by me”