Contributor: Bruno Miguel Ferreira Alves

Over several years of practice, I have developed a particular interest in wounds and all its surroundings. As a nurse in an orthopedic inpatient unit, I am confronted daily with clients who have something in common – a wound – the surgical wound. The surgical wound creates an element of discomfort for all clients. It is essential, then, to understand what comfort is.

For nursing, comfort has been defined as the active, passive, or cooperative satisfaction of fundamental human needs regarding relief, tranquillity, and transcendence of stressful healthcare situations (Kolcaba, 1994). Comfort is a holistic outcome that starts from a person’s response to complex stimuli in various domains. Its acquisition facilitates physical and psychological gains(Kolcaba, 1994). Kolcaba developed the Comfort Theory, a middle-range, normative and descriptive theory of nursing care. This theory divides comfort into two dimensions. The first dimension consists of three states:

• relief, translated as the experience of having a specific need met;
• tranquillity, translated as a state of calm or contentment; and
• transcendence, translated as the state where each individual can overcome their problems.

The second dimension focuses on the context in which comfort occurs, which is:

• physical, relative to bodily sensations;
• psychospiritual, related to self-awareness in which esteem,
• sexuality, meaning in life, and the relationship with particular order or entity are included; social, where interpersonal, family and cultural relationships are included; and
• environmental, where factors such as light, noise, environment, color, temperature, and natural/synthetic elements are inserted.

The two dimensions juxtaposed form a table with twelve facets of Comfort (Kolcaba, 1994). Comfort Theory identifies that from a situation, such as that of a surgical process, stimuli emerge by new needs for the acquisition of comfort that cause negative tensions (Kolcaba et al., 2006).

Discomfort is more than a negative physical sensation or emotional distress in which the various aspects of comfort and discomfort affect holistic beings (Kolcaba et al., 2006). Negative tensions represent an absence of balance, which arises when the obstructive forces overcome the facilitating forces. The need for comfort makes us focus our interventions (nursing interventions) to move the tension in a positive direction, as perceived by the client. Subsequently, the intervention is evaluated by the nursing team (Kolcaba, 1994).

Increased comfort indicates that the negative tensions were reduced by achieving positive pressure, which allows for a behavioral construction. The nursing team facilitates the outcome of comfort because it is theoretically related to internal or external health-seeking behaviors and constructive interest, which allow for higher gains when trained (Kolcaba, 1994).
Theoretically, comfort is achieved when all comfort needs are met. However, achieving an enhanced comfort level above a baseline is the most expected outcome to be completed in stress-causing health situations(Boudiab & Kolcaba, 2015).

Healthcare teams can base their interventions using the prepositions of Comfort Theory. Initially, the health care team uses the taxonomic structure of the Comfort Theory to identify clients with comfort needs. For these, interventions are designed to address the needs found; subsequently, the intervention variables that are not readily amenable to change are identified. We can name the intervention a comfort measure if it is effective (Boudiab & Kolcaba, 2015).

The goals set should be realistic and achievable. If several goals are reached, the client is strengthened and committed to achieving other goals. Clients and families in the care plan reach goals, are more satisfied, and promote a positive health rate. A good environment produces better results both at the client and at the institutional level (Boudiab & Kolcaba, 2015).

After several years of pre and post-operative nursing practice, it was possible to identify several changes in the client with a surgical wound, which are also commonly attributed to the person with an injury. The surgical wound is a moment of adversity for the client and his family, in which several issues emerge. In addition to objective data, including the type of wound, the stage of healing, the conditions of the wound bed, and the surrounding skin, subjective data should also be addressed, as they also affect the expected results. Psychological factors such as anxiety and depression, social isolation, low economic status, and pain are examples of factors associated with delayed wound healing and causing discomfort. The presence of the wound generates psychological problems, which are associated with beliefs, values, body image changes, stress, and ineffective symptom management that can lead to the wound being the main daily focus. The problem may lead to depression and isolation, often originating in pain, guilt, sleep deprivation, restricted mobility, the presence of exudate, and consequent lousy odor. Adopting various coping mechanisms to minimize the discomfort-generating effects caused by the wound is essential. Referral to social support, religion, hobbies, and information about the dressing material used, thus participating in the therapeutic plan, are strategies to be adopted by nurses to rebuild self-esteem, thus generating hope. Procedures such as listening, encouraging the patient to talk, and including family and friends are key empowerment strategies for patients to gain control of their situation (Parreira & Marques, 2017).
The behavior of the nursing team influences the person’s perception of comfort, leading to a more significant commitment to the jointly outlined interventions (Wensley et al., 2020).

It is necessary for the healthcare team, specifically the nursing team, to care for the psychological and physical dimensions of the person. Several studies show that the client’s possible discomfort can change the wound healing phase. In everyday life, comfort is an aspect not considered by the healthcare team (Gayatri et al., 2020). After the main changes experienced by patients are identified, although scientific evidence emphasizes pain, it is also easy to identify the role of the nursing team in optimizing comfort in patients with surgical wounds. It is possible to determine that the Theory of Comfort easily applies to the topic under analysis and may lead to several case studies.

Naturally, it is necessary to reflect on my reality in which there are several evident concerns about the person’s physical image and the discomfort caused by the tugging caused by the wound itself, which is not readily identifiable in the scientific evidence. Thus, the most frequent nursing diagnoses were: knowledge about wound care compromised, current surgical wound, the potential risk to body image, impaired elimination, present anxiety, current pain, initiated surgical recovery, and impaired family process. It is thus possible to identify a cross-cutting issue.

Throughout hospitalization, several nursing interventions are outlined, such as effective pain control through the adoption of pharmacological and non-pharmacological strategies, anxiety control, familiarisation of the patient and their family with the new physical limitations (mobility and aesthetics), the need to adapt to elimination limitations, the preparation of the patient for motor rehabilitation, as well as the structure of the unit to optimize the identified diagnoses.

In my daily practice it is possible to recognize that patients who have their expectations met experience greater comfort, reveal less anxiety, translating into more effective rehabilitation and consequently a safe discharge. A patient who is familiarised with their surgical wound throughout their hospital stay, aware of their new limitations, has a greater capacity for rehabilitation. To this end, it is essential that the negative aspects are converted into positive aspects throughout the hospitalisation, providing the user with fundamental coping strategies to allow the management of their daily life.

Despite the existence of scientific evidence related to the topic under analysis, that evidence is limited, difficult to access, and not very specific regarding the specific interventions of the nursing team. The evidence is also mainly directed to younger patients, which translates into future research challenges.

Bibliography

Boudiab, L. D., & Kolcaba, K. (2015). Comfort theory: Unraveling the complexities of veterans’ health care needs. Advances in Nursing Science, 38(4), 270–278. https://doi.org/10.1097/ANS.0000000000000089

Gayatri, D., Nurachmah, E., Mansyur, M., Soewondo, P., & Suriadi, S. (2020). Relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in Indonesia: A cross-sectional study. Aquichan, 20(3), 1–10. https://doi.org/10.5294/aqui.2020.20.3.3

Herdman, T., Kamitsuru, S., & Lopes, C. (2021). NANDA International Nursing Diagnoses: Definitions and Classification 2021-2023. In NANDA International Nursing Diagnoses: Definitions and Classification 2021-2023. Georg Thieme Verlag Stuttgart, New York. https://doi.org/10.1055/b000000515

Kolcaba, K., Tilton, C., & Drouin, C. (2006). Article in JONA The Journal of Nursing Administration. The Journal of Nursing Administration, 36(11), 538–544. https://www.researchgate.net/publication/6698936

Kolcaba, K. Y. (1994). A theory of holistic comfort for nursing ‘The Relationship between Comfort and Adherence in Hemodialysis Patients’ View project A theory of holistic comfort for nursing. Journal of Advanced Nursing, 19, 1178–1184. https://www.researchgate.net/publication/15269336

Parreira, A., & Marques, R. (2017). Feridas – Manual de Boas Práticas (1st ed.). Lidel – Edições Técnicas, Lda.

Pinto, R., Soares, H., Melo, E., Pestana, H., Cardoso, A., Morais, E., Silva, M., & Paulino, C. (2016). CIPE versão 2015 – Classificação Internacional para a Prática de Enfermagem – Edição Portuguesa – Ordem dos Enfermeiros – maio de 2016. Lusodidacta.

Wensley, C., Botti, M., McKillop, A., & Merry, A. F. (2020). Maximising comfort: How do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings. BMJ Open, 10(5). https://doi.org/10.1136/bmjopen-2019-033336

About Bruno Miguel Ferreira Alves

I finished my degree in 2016 at the Escola de Enfermagem São João de Deus – Universidade de Évora. Since 2016, I have worked at the Orthopedic Service of Hospital de Santa Maria (CHULN) in Lisboa, Portugal. Over the years, I have become interested in wounds, having done a Postgraduate Course in Wound Intervention in 2018 at the Universidade de Évora. I also belonged to a scientific society in the area, ELCOS Sociedade Portuguesa de Feridas, specifically to the Lisbon Regional Council. In 2022, I started the Master’s Degree in Community Nursing at the Universidade Católica Portuguesa in Lisboa, and this post was carried out within the scope of the curricular unit of Nursing Theories, under the pedagogical supervision of Professor Zaida Charepe (PhD, Associate Professor).