Nursing Diagnosis: Application to Clinical Practice
11th Edition

Impaired Comfort
DEFINITION
Impaired Comfort: The state in which a person experiences an uncomfortable sensation in response to a noxious stimulus
DEFINING CHARACTERISTICS
Major (Must Be Present)
The person reports or demonstrates discomfort.
Minor (May Be Present)
Autonomic response in acute pain
  • Increased blood pressure
  • Increased pulse
  • Increased respirations
  • Diaphoresis
  • Dilated pupils
Guarded position
Facial mask of pain
Crying, moaning
Abdominal heaviness
Nausea
Vomiting
Malaise
Pruritus
RELATED FACTORS
Any factor can contribute to impaired comfort. The most common are listed below.
Biopathophysiologic
Related to uterine contractions during labor
Related to trauma to perineum during labor and delivery
Related to involution of uterus and engorged breasts
Related to tissue trauma and reflex muscle spasms secondary to:
Musculoskeletal disorders
  • Fractures
  • Contractures
  • Spasms
  • Arthritis
  • Spinal cord disorders
Visceral disorders
  • Cardiac
  • Renal
  • Hepatic
  • Intestinal
  • Pulmonary
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Cancer
  • Vascular disorders
  • Vasospasm
  • Phlebitis
  • Occlusion
  • Vasodilation (headache)
Related to inflammation of:
  • Nerve
  • Tendon
  • Bursa
  • Joint
  • Muscle
  • Juxta-articular structures
Related to fatigue, malaise, or pruritus secondary to contagious diseases:
  • Rubella
  • Hepatitis
  • Pancreatitis
  • Chicken pox
  • Mononucleosis
Related to effects of cancer on (specify)
Related to abdominal cramps, diarrhea, and vomiting secondary to:
  • Gastroenteritis
  • Gastric ulcers
  • Influenza
Related to inflammation and smooth muscle spasms secondary to:
  • Renal calculi
  • Gastrointestinal infections
Treatment-Related
Related to tissue trauma and reflex muscle spasms secondary to:
  • Surgery
  • Burns
  • Accidents
  • Diagnostic tests (venipuncture, invasive scanning, biopsy)
Related to nausea and vomiting secondary to:
  • Chemotherapy
  • Side effects of (specify)
  • Anesthesia
Situational (Personal, Environmental)
Related to fever
Related to immobility/improper positioning
Related to overactivity
Related to pressure points (tight cast, elastic bandages)
Related to allergic response
Related to chemical irritants
Related to unmet dependency needs
Related to severe repressed anxiety
Maturational
Related to tissue trauma and reflex muscle spasms secondary to:
Infancy: Colic
Infancy and early childhood: Teething, ear pain
Middle childhood: Recurrent abdominal pain, growing pains
Adolescence: Headaches, chest pain, dysmenorrhea
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Focus Assessment Criteria
This nursing assessment of pain is designed to acquire data for assessing a person’s adaptation to pain, not for determining the cause or existence of pain.
Subjective Data
Assess for Defining Characteristics.
Pain
“Where is your discomfort located; does it radiate?” (Ask child to point to place).
“When did it begin?”
“Can you relate the cause of this discomfort?” or “What do you think has caused your discomfort?”
“Describe the discomfort and its pattern.”
  • Time of day
  • Duration
  • Quality/intensity
  • Frequency (constant, intermittent, transient)
Ask person to rate the pain: at its best, after pain-relief measures, and at its worst. Use consistent scale, language, or set of behaviors to assess pain.
For adults, use an oral or visual analogue scale of 0 to 10 (0 = no pain, 10 = worst pain ever).
For children, select a scale appropriate for developmental age: can use scale for assessed age or younger; include child in selection.
  • 3 years and older: Use drawings or photographs of faces (Oucher scale) ranging from smiling to frowning to crying with numeric scale (Beyer, 1984).
  • 4 years and older: Use four white poker chips to ask child how many pieces of hurt he or she feels (no hurt = no chips; Hester, 1979).
  • 6 years and older: Use a numeric scale, 0 to 5 or 0 to 10 (verbally or visually); use blank drawing of body, front and back, asking child to use three different crayons to color places with a little pain, medium pain, and a lot of pain (Eland Color Tool).
“How do you usually react to pain (crying, anger, silence)?”
“Are any other symptoms associated with your discomfort (nausea, vomiting, numbness)?”
Effects of pain
“Do you talk to others about your discomfort (spouse, friends, nurse)?” “To whom do you talk?” Ask client to indicate if each of the following increases, decreases, or has no effect on discomfort.*
  • Liquor
  • Stimulants (eg, caffeine)
  • Eating
  • Heat
  • Cold
  • Damp
  • Weather changes
  • Massage
  • Vibration
  • Pressure
  • No movement
  • Movement/activity
  • Sleep, rest
  • Lying down
  • Distraction (eg, TV)
  • Urination
  • Defecation
  • Tension
  • Bright lights
  • Loud noises
  • Going to work
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  • Intercourse
  • Mild exercise
  • Fatigue
Ask person what effect pain has had or is anticipated to have on the following patterns:
Work/activity (work/home activities, leisure/play)
Relationships/relating (wanting to be alone, with people)
Sleep (difficulty falling asleep/staying asleep)
Eating (appetite, weight gain/loss)
Elimination (bowel, constipation/diarrhea, bladder)
Menses
Sex (libido, function)
Cultural effects on pain (Weber, 1996)
  • Country of origin
  • Time in United States
  • Native language
  • Ability to understand/speak
  • Availability of interpreter
  • Religious practices (blood transfusion, specific clothing, male attendants)
  • Food, beverage preferences
  • Hygiene practices
Pruritus
  • Onset
  • Precipitated by what
  • Site(s)
  • Relieved by what
  • History of allergy (individual, family)
Nausea/vomiting
  • Onset, duration
  • Vomitus (amount, appearance)
  • Frequency, severity
  • Relief measures
Objective Data (Acute/Chronic Pain)
Assess for Defining Characteristics.
Behavioral manifestations
  • Mood
  • Calmness
  • Moaning
  • Grimacing
  • Pacing
  • Restlessness
  • Withdrawn
  • Eye movements
  • Fixed
  • Searching
  • Crying
  • Open
  • Closed
  • Perceptions
  • Oriented to time and place
Musculoskeletal manifestations
  • Mobility of painful part
  • Full
  • Limited/guarded
  • No movement
  • Muscle tone
  • Spasm
  • Tenderness
  • Tremors (in effort to hide pain)
Dermatologic manifestations
  • Color (redness)
  • Temperature
  • Moisture/diaphoresis
  • Edema
Cardiorespiratory manifestations
  • Cardiac
  • Rate
  • Blood pressure
  • Palpitations present
  • Respiratory
  • Rate
  • Rhythm
  • Depth
Sensory alterations
  • Paresthesia
  • Dysesthesias
Developmental manifestations
  • Infant
  • Irritability
  • Changes in eating or sleeping
  • Inconsolability
  • Generalized body movements
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Toddler
  • Irritability
  • Aggression (kicking, biting)
  • Sucking
  • Changes in eating or sleeping
  • Rocking
  • Clenched teeth
Preschool
  • Irritability
  • Aggression
  • Changes in eating or sleeping
  • Verbal expressions of pain
School-aged
  • Changes in eating or sleeping
  • Verbal expressions of pain
  • Change in play patterns
  • Denial of pain
Adolescent
  • Mood changes
  • Verbal expressions when asked
  • Behavior extremes (“acting out”)
  • Changes in eating or sleeping
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The client will report acceptable control of symptoms.
Indicators
  • Describe factors that increase symptoms.
  • Describe measures to improve comfort.
General Interventions
Assess for Sources of Discomfort.
  • Pruritus
  • Fever
  • Prolonged bed rest
Reduce Pruritus and Promote Comfort.
Maintain Hygiene without Producing Dry Skin.
Encourage frequent baths.
  • Use cool water when acceptable.
  • Use mild soap (Castile, lanolin) or a soap substitute.
  • Blot skin dry; do not rub.
Apply cornstarch lightly to skin folds by first sprinkling on hand (to avoid caking of powder); for fungal conditions, use antifungal or antiyeast powder preparations [Mycostatin (nystatin)], or miconazole cream.
Massage pruritic scar tissue with cocoa butter daily (Field et al., 2000).
Prevent Excessive Dryness.
Lubricate skin with a moisturizer unless contraindicated; pat on with hand or gauze.
Apply lubrication after bath, before skin is dry, to encourage moisture retention.
Apply wet dressings continuously or intermittently to relieve itching and remove crusts and exudate.
Provide 20- to 30-min tub soaks of 32°F to 38°F; water can contain oatmeal powder, Aveeno, cornstarch, or baking soda.
Promote Comfort and Prevent further Injury.
Advise against scratching; explain the scratch–itch–scratch cycle.
Secure order for topical corticosteroid cream for local inflamed pruritic areas; apply sparingly and occlude area with plastic wrap at night to increase effectiveness of cream and prevent further scratching.
Secure an antihistamine order if itching is unrelieved.
Use mitts (or cotton socks), if necessary, on children and confused adults.
Maintained trimmed nails to prevent injury; file after trimming.
Remove particles from bed (food crumbs, caked powder).
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Use old, soft sheets and avoid wrinkles in bed; if bed protector pads are used, place draw sheet over them to eliminate direct contact with skin.
Avoid using perfumes and scented lotions.
Avoid contact with chemical irritants/solutions.
Wash clothes in a mild detergent and put through a second rinse cycle to reduce residue; avoid use of fabric softeners.
Prevent excessive warmth by use of cool room temperatures and low humidity, light covers with bed cradle; avoid overdressing.
Apply ointments with gloved or bare hand, depending on type, to lightly cover skin; rub creams into skin.
Use frequent, thin applications of ointment, rather than one thick application.
Proceed with Health Teaching, when Indicated.
Explain causes of pruritus and possible prevention methods.
Explain factors that increase symptoms (eg, low humidity, heat).
Explain interventions that relieve symptoms (eg, fluid intake of 3,000 mL/day unless contraindicated).
Advise about exposure to sun and heat and protective products.
Teach person to avoid fabrics that irritate skin (wool, coarse textures).
Teach person to wear protective clothing (rubber gloves, apron) when using chemical irritants.
Refer for allergy testing, if indicated.
Provide opportunity to discuss frustrations.
For further interventions, refer to Ineffective Coping if pruritus is stress related.
For Excessive Warmth, Provide Comfort Measures as Indicated.
Keep the room cool; remove blankets as needed.
Offer a cool washcloth for forehead; change frequently to maintain coolness.
Provide tepid sponge baths or alcohol rubs; finish with powder to minimize moisture.
Monitor bed linens (especially pillowcase) for dampness; change linens whenever moist.
Encourage wearing absorbent cotton bedclothes rather than silk or nylon.
Flip pillows and straighten linens frequently; assist with frequent repositioning.
Provide for periods of uninterrupted rest.
If requested, provide distractions (eg, TV, magazines, visitors).
Consult with physician about the use of aspirin and acetaminophen on an alternating basis (aspirin q 4 h with acetaminophen q 4 h in between).
For Coldness, Provide Comfort Measures as Indicated.
Apply socks, gloves, or head covering as needed.
Monitor room temperature; keep thermostat at 75°F to 80°F and monitor client’s temperature for response.
If possible, encourage taking a warm tub bath; offer hot liquids.
Provide warmed blankets.
Consult with a physician for use of a rewarming device.
For a Person on Bed Rest:
Vary position at least every 2 h unless other variables necessitate more frequent changes.
Use small pillows or folded towels to support limbs.
Vary positions with flexion and extension, abduction, or adduction.
Use prone position if tolerable.
Rationales
  • Excessive warmth or dryness, rough fabrics, fatigue, stress, and monotony (lack of distractions) aggravate pruritus (Thorns & Edmonds, 2000).
  • Methods that interrupt pain also will interrupt pruritus. Examples include local anesthetics, cold, and peripheral nerve resection.
  • Coolness reduces vasodilatation.
  • Dryness increases skin sensitivity by stimulating nerve endings.
  • Scratching stimulates histamine release, increasing pruritus.
  • Massaging pruritic scars decreases itching, pain, and anxiety (Field et al., 2000).
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Rationales
See Rationales for General Interventions.
Rationales
  • Approximately 50% of all pregnant women report backache; causes include postural changes, relaxation of pelvic ligaments, and movement of symphysis pubis (Davis, 1996).
  • Lowered serum calcium and increased phosphate levels are thought to increase neuromuscular irritability.