Promoting Comfort:
Moving Beyond Pain
Management
Tara Foote RN, BSN, OCN
Objectives
Identify several nonpharmacological interventions to
promote patient comfort
Understand the importance of nursing presence in
alleviating suffering
Learn to apply nursing theory to positively impact
quality of life and comfort
Understand how to engage the interdisciplinary team
to provide holistic comfort measures to patients in
distress or discomfort
Managing pain is far more than the giving of pain
medication. Nurses demonstrate compassion as
they listen to the patient’s description of pain,
validate its presence and importance, and offer
their commitment to relieving the pain. (Ferrel &
Coyle, 2008)
Pain Basics: A Brief Review
Pain Definitions
“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage.” (Agency for
Health Care Policy and Research, 1994)
“What the patient says it is, existing whenever he or
she says it does.” (Institute for Clinical Systems
Improvement, 2008)
Types
of
Pain
Nocioceptive Pain: nerve fibers within bodily tissues
perceive noxious stimuli, usually responds to NSAID
and narcotic medication and has a brief duration
Somatic pain arises from damage to bodily
tissues and is usually well-localized (e.g. I cut
my arm)
Visceral pain is mediated by stretch receptors
and is usually poorly localized, deep, dull, and
cramping (e.g. uterine cramping, gas pain, liver
pain)
Musculoskelatal pain arises from the bones and
associated structures, tending to be
inflammatory-type pain (e.g. tendonitis, twisted
Types of Pain
Neuropathic pain: arises from abnormal neural
activity secondary to disease, injury or dysfunction of
the nervous system
Can be further subdivided into sympathetically
mediated pain, peripheral neuropathic pain or
central pain (arising from the CNS)
Sensory experience ranges from sharp,
shooting, burning pain to numbness and
tingling
Tends to respond better to anticonvulsant,
antispasmodic and antidepressant
medications than narcotics and NSAIDS alone
Acute vs. Chronic Pain
Serves as a warning that something is wrong
Response to actual bone or tissue injury
Generally viewed as a time-limited experience
Responds to traditional pain medications (NSAIDS,
narcotics)
Has no apparent biological value
Persists beyond the time required for the body to
heal
Worsens and intensifies over time
Requires multifaceted approach to achieve pain
Pain Assessment
OLDCART
O = Onset
L = Location
D = Duration
C = Characteristics
A = Aggravating factors
R = Relieving factors
T = Treatment
Pain Assessment
The ABCDE acronym
A = Ask about pain regularly. Assess pain
systematically.
B = Believe patients’ reports of pain and what
relieves it
C = Choose pain control options appropriate for the
patient, family, and setting.
D = Deliver interventions in a timely, logical, and
coordinated fashion.
E = Empower patients and their families. Enable
them to control their course to the greatest extent
possible.
Sometimes
Medication
Just Isn’t
Enough
Pain vs. Suffering
Suffering Defined
Suffering is experienced by persons, not merely by
bodies, and has its source in challenges that
threaten the intactness of the person as a complex
social and psychological entity (Cassell, 1982)
A state of anguish in one who bears pain, injury, or
loss (Copp, 1974)
Suffering can be looked at in physical, personal,
family, and spiritual aspects
Physical Suffering
Not all physical suffering is caused by pain, and not all pain is
identified by the patient as physical suffering. Assess the following
sources:
physical discomfort that patients don’t identify as pain (aching,
pressure, spasm, cramping, numbness, tingling)
discomfort or distress from immobility
sleeplessness
chills or fever
declining functional ability and increasing dependence on others
changes in appearance
skin problems (itching, inflammation, wounds)
odors from bodily fluids or wounds
Personal and Family
Suffering
How much are you suffering because of loss of
enjoyment of life?
How much are you suffering because of your
feelings for and relationships with family and friends?
How much are you suffering because of your
concern for your loved ones?
How much are you suffering because of fear of the
future?
How much are you suffering because of unfinished
business?
Spiritual Suffering
Can also be viewed as existential suffering or the
search for meaning, hope or connection with oneself,
others or a higher power.
How much are you suffering relative to your ability
to interact with your spiritual tradition?
How much are you suffering relative to your ability
to find strength in your belief system?
How much are you suffering relative to your
feelings about your personal sources of inner
strength?
Ten Tenets of Suffering
It is a loss of control, creating insecurity. Suffering people
often feel helpless, trapped, and unable to escape their
circumstances.
Suffering is often associated with loss. It may be loss of a
relationship or some aspect of self, or loss of some aspect of
the physical body. The loss may only be evident in the mind
of the sufferer, but leaves the person feeling diminished and
broken.
Suffering is an intensely personal experience.
It encompasses a range of intense emotions including
sadness, anguish, fear, abandonment, and despair.
Suffering forces one to confront their own mortality. In the
face of serious illness, some may fear death while others may
yearn for death.
Suffering often begs the question “Why?” Illness or loss may be
seen as untimely or undeserved. People may seek meaning
and answers for that which is unknowable.
It is often associated with separation from the world. People
may express intense loneliness and desire for connection with
others while also feeling intense distress about dependency on
others.
Suffering can produce spiritual distress, feelings of
hopelessness, self-reflection of lived experiences and what
remains undone, and reevaluation of one’s relationship with a
higher power.
Although not synonymous with suffering, pain can produce
psychological, spiritual and social distress. Pain which persists
without meaning becomes suffering.
Suffering occurs when individuals feel voiceless or unheard.
How Can
Nursing
Theory
Guide Us?
Quality of Life Model
by
Betty Ferrell (1996)
Quality of Life Model
Physical Well Being
Social Well Being
Fatigue
Sleep Disruption
Function
Nausea
Appetite
Constipation
Aches/Pains
Isolation
Role Adjustment
Financial Burden
Roles/Relationships
Affection/Sexual Function
Leisure Activities
Burden
Employment
Quality
of
Life
Psychological Well Being
Anxiety
Depression
Helplessness
Difficulty Coping
Fear
Uselessness
Concentration
Control
Distress
Spiritual Well Being
Meaning
Uncertainty
Hope
Religiosity
Transcendence
Positive Change
The Process of Pain
Impacting Quality of Life
Physical
appetite
function
sleep
fatigue
Chemo
(Immediate
Cause)
Physiologic
Effects
(Immediate
Effect)
PAIN
Social
isolation
finances
sexuality
leisure
(Patient
Sypmtom)
Spiritual
Psychological
anxiety
depression
helplessness
concentration
fear
meaning
hopeless
uncertainty
Suffer
ing
How Can
Nursing
Theory
Guide Us?
Comfort Theory
by
Katharine Kolcaba
Comfort Theory
Middle range nursing theory developed in the 1990’s for health
practice, education and research drawn from nursing, medicine,
psychology, psychiatry, ergonomics and English literature
Holistic comfort is defined as the immediate experience of being
strengthened through having the needs for relief, ease, and
transcendence met in four contexts of experience (physical,
psychospiritual, social, and environmental). (Kolcaba & Fisher, 1996)
Types of Comfort
Relief: the state of having a discomfort
mitigated or alleviated or having had a
specific need met
Ease: a state of calm or contentment or the
absence of a specific discomfort
Transcendence: the state in which one
rises above one's problems or pain even
when they cannot be eradicated or avoided
Contexts of Comfort
Physical: pertaining to bodily sensations and
homeostatic mechanisms.
Psychospiritual: pertaining to internal awareness
of self, including esteem, concept, sexuality, and
meaning in one's life; one's relationship to a
higher order or being.
Environmental: pertaining to external
surroundings, conditions, and influences.
Sociocultural: pertaining to interpersonal, family,
and societal relationships. Also to family
traditions, rituals, and religious practices.
Types of Care
Technical
(maintains
homeostasis)
Coaching
(relieve anxiety, plan
for recovery)
Comforting
(unexpected things)
-care for and strengthen
-monitor & manage
pain, nausea,
dyspnea, etc.
-prevent
complications
-administer
medications
-observe for side
effects
-reassure
-educate
-environmental
interventions
-provide hope
-massage, touch,
holding a hand
-active listening
-providing opportunities
for life review
-help plan for
optimizing health
-calm presence
-encourage
-creating a memorable
connection
Case Study
74 year old client in own home with 70 year old wife (Mr. & Mrs.
Green). Recently, Mr. Green has had weight loss, nausea and
abdominal pain. Mrs. Green is anxious when present at physical
exam where Mr. Green is diagnosed with pancreatic cancer with
liver metastases.
Sociocultural
Physical
-pain
-nausea
-anorexia
-jaundice
Psychospiritual
-anger
-anxiety
-questioning meaning
-depression
-many treatment
options, side effects
-financial distress
-wife’s anxiety
-body image, selfesteem
Environmental
-transportation issues
-uncomfortable wait room
-cold treatment rooms
-bright lights
-hallway noise
Total
Comfort
Relief
Ease (maintenance) Transcendence
Physical
Narcotic pain medication
Anti-nausea medication
Radiation to liver mets
pain rated at goal
able to eat without
vomiting
reduction in jaundice
meets with dietician to
develop nutritional plan
reengages in leisure
activities
Psychospiritual
Chaplain and social work consults
Encourage
Nursing presence and active
listening
adherence to plan
patient reports less
anxiety and more
positive mood
pt and wife participate in
support groups
find meaning in illness,
renewed sense of faith
Sociocultural
Provide information on treatment
options and side effects
Enlist social work to assist with
disability paperwork
Include wife in teaching and care
Provide soft hats after hair loss
fully understands
treatment plan
feels able to identify
and manage sideeffects
wife reports less
anxiety
Engages family and social
support system in care plan
wife starts volunteering
with a group to knit hats
Environmental
Provide warm blankets
Make office decor comfortable and
patient friendly
Arrange medical transport
Provide headphones and eye pillows
P
pt feels comfortable in
treatment spaces
pt consistently arrives
to clinic
Pt’s church fundraises for
new treatment chairs
Pt uses guided imagery to
create comfort during
treatment
Intervening Variables: factors unlikely to change and over which providers have little control
(prognosis, financial situation, etc)
Health seeking behaviors: behaviors the patient engages in that facilitate health or a peaceful
death. They can be measurable outcomes that are either internal (healing, T-cell formation,
oxygenation,) or external (observable behaviors such as working in therapy, shortened length of
stay)
Institutional Integrity: values, financial stability and wholeness of health care organizations at
local, regional, state and national levels
Best Policies: protocols and procedures developed by an institution for overall use after
collecting evidence
Putting It
All
Together:
Using Nursing Presence
and Communication to
Provide Comfort
Nonpharmacological
Interventions
heat/cold
deep breathing
repositioning
elevation
distraction
music therapy
prayer
massage
Cognitive-behavioral approaches: biofeedback,
guided imagery, hypnosis, passive relaxation,
progressive muscle relaxation
Guided imagery is a gentle but powerful technique that
focuses and directs the imagination to promote healing,
relaxation, and pain and anxiety relief. Going through
an entire exercise may be time-intensive but nurses
can develop skills to enhance their practice or direct
patients and caregivers to do exercises on their own.
http://www.cancer.med.umich.edu/support/guided_imagery_podcasts_descriptions.sht
ml
http://www.innerhealthstudio.com/
Jill Lematta Learning Center
CD’s and downloads available on line, at bookstores and libraries
Social Work consult (may be able to provide resources)
Nursing Process as
Intervention
Nursing was born out of the desire to provide comfort.
As technology advances, we increasingly move to a “fixit” medical model focused on outcome more than
process.
Nurses can respond to suffering by
Assessing sources of pain and suffering, such as shame, feelings of
abandonment and isolation
Diagnosing sources of suffering to identify those that can be relieved,
witnessed or supported
Intervening through presence, listening and communication that
enables patient expression and by eliminating sources of suffering
Evaluation to allow alterations in the plan of care and recognition of
new problems to meet patients’ needs
Presence
Benner described skill acquisition of nurses as they
progress from novice to expert
“Presencing” is one of the eight competencies of
the nurse’s helping role
Behaviors of expert nurses are committed and
involved, contributing to the patient’s
personhood, meaning and dignity
Expert nurses knew their “being” was sometimes
more important than their doing
Presence Defined (from Schaffer &Norlander, 2009)
Being available with the wholeness of one’s
being
Encountering the patient as a unique human
being in a unique situation and choosing to
“spend” oneself on the patient’s behalf
Intuitive knowing or sensing another’s needs for
help and making self physically available to be
present in a helping way
A subject-to-subject interrelationship that honors
the ever-changing reality of the other
Key Elements of Nursing
Presence
Attentiveness: being in the moment focused on the patient’s
message
Accountability: doing the right thing, invested and committed
Sensitivity: knowing the patient as a unique person
Touching: massage, turning, positioning and teaching families to
help
Openness: willing to enter another’s experience bringing one’s
authentic self
Active Listening: hearing beneath the words to their meaning,
using silence
Acknowledging: life review, seeing the patient as still having
Death is awful, demonic. If you think your task as
comforter is to tell me that really, all things considered,
it’s not so bad, you do not sit with me in my grief but
place yourself off in the distance away from me. Over
there, you are of no help. What I need to hear from you
is that you recognize how painful it is. I need to hear
from you that you are with me in my desperation. To
comfort me, you have to come close. Come sit beside
References
Agency for Health Care Policy and Research. (1994). Management of cancer
pain, clinical practice guideline number 6. Rockville, MD: U.S. Department of
Health and Human Services.
Cassell, E. (1982). From Ferrell, B. R. & Coyle, N. (2008). The Nature of
Suffering and the Goals of Nursing. New York: Oxford University Press.
Copp, L. (1974). From Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering
and the Goals of Nursing. New York: Oxford University Press.
Ferrell, B. R. & Coyle, N. (2008). The Nature of Suffering and the Goals of
Nursing. New York: Oxford University Press.
Ferrell, B. R., & Coyle, N. (2010), Oxford Textbook of Palliative Nursing. New
York: Oxford University Press.
Institute for Clinical Systems Improvement. (May, 2008). Health care guideline:
Palliative care. Retrieved 14 October 2008 from
http://www.icsi.org/palliative_care/palliative_care_11918.html
Kolcaba, K. (201o). An introduction to comfort theory. Retrieved December 2,
2012 from http://www.thecomfortline.com
Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nursesensitive outcome. Advances in Nursing Science, 15(1), 1-10.
Kolcaba, K. & Fisher, E. (1996). A holistic perspective on comfort care as an
advance directive. Critical Care Nursing Quarterly, 18(4), 66-76.
Kolcaba, K., Tilton, C, & Drouin, C. (2006). Comfort theory: A unifying
framework to enhance the practice environment. Journal of Nursing
Administration, 36(11), 538-544.
March, A. & McCormack, D. (2009). Nursing theory-directed healthcare:
Modifying Kolcaba’s Comfort Theory as an institution-wide approach. Holistic
Nursing Practice, March/April, 75-80.
Norlander, L. (2008). To Comfort Always: A Nurse’s Guide to End-of-Life Care.
Indianapolis: Sigma Theta Tau International.
Schaffer, M. & Norlander, L. (2009). Being Present: A Nurse’s Resource for
End-of-Life Communication. Indianapolis: Sigma Theta Tau International.
Smith, H. & Aronson, M. Definition and pathogenesis of chronic pain. UpToDate
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