IMPAIRED COMFORT

Acute Pain

Chronic Pain

Chronic Pain Syndrome

Labor Pain

Nausea

Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural, and social dimensions

Anxiety

Crying

Difficulty relaxing

Expresses discomfort

Expresses discontentment with situation

Expresses fear

Expresses feeling cold

Expresses feeling warm

Expresses itching

Expresses psychological distress

Irritable mood

Moaning

Psychomotor agitation

Reports altered sleep-wake cycle

Reports hunger

Sighing

Uneasy in situation

NANDA-I approved*

Any Factor Can Contribute to Impaired Comfort. The Most Common Are Listed Below

Pathophysiologic

For labor pain, refer to Labor Pain.

Related to tissue trauma and reflex muscle spasms secondary to:

Musculoskeletal Disorders

Fractures

Contractures

Spasms

Arthritis

Spinal cord disorders

Fibromyalgia

Visceral Disorders

Cardiac

Renal

Hepatic

Cancer

Intestinal

Pulmonary

Vascular Disorders

Vasospasm

Occlusion

Phlebitis

Vasodilation (headache)

Related to inflammation of, or injury to:

Nerve

Tendon

Bursa

Joint

Muscle

Juxta-articular structures

Related to fatigue, malaise, or pruritus secondary to contagious diseases:

Rubella

Hepatitis

Pancreatitis

Chicken pox

Mononucleosis

Iron-deficiency anemia

Related to abdominal cramps, diarrhea, and vomiting secondary to:

Influenza

Gastroenteritis

Treatment Related

Related to nausea and vomiting secondary to:

Anesthesia

Chemotherapy

Side effects of (specify)

Situational (Personal, Environmental)

Related to inadequate control over environment*

Related to inadequate health resources*

Related to inadequate situational control*

Related to unpleasant environmental stimuli*

Related to insufficient privacy*

Related to immobility/improper positioning

Related to pressure points (tight cast, elastic bandages)

Related to allergic response

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

Illness-related symptoms

Treatment regimen

AUTHOR'S NOTE

Impaired Comfort can represent various uncomfortable sensations (e.g., pruritus, immobility, NPO status). For an individual experiencing nausea and vomiting, the nurse should assess whether Impaired Comfort or Imbalanced Nutrition is appropriate. Short-lived episodes of nausea, vomiting, or both (e.g., postoperatively) are best described with Impaired Comfort related to effects of anesthesia or analgesics. When nausea/vomiting may compromise nutritional intake, the appropriate diagnosis may be Risk for Imbalanced Nutrition related to nausea and vomiting secondary to (specify). Impaired Comfort also can be used to describe a cluster of discomforts related to a condition or treatment, such as radiation therapy.

Level 1 Fundamental Focused Assessment (all settings)

Onset of pruritus

Site(s)

What makes it worse?

Precipitated by what?

Relieved by what?

History of allergy (individual, family)

The individual will report acceptable control of symptoms as evidenced by the following indicators:

• Describes factors that increase symptoms
• Describes measures to improve comfort

CARP'S CUES

Pruritus can present with or without generalized rash. Chronic itch (> 6 weeks) has a prevalence of approximately 17% in adults and may be higher in elderly (> 65 years), where the figure is likely to be 50% or higher (Millington et al., 2018). One study reported that, of a group of individuals with generalized pruritus without a rash (*GPWOR) as well as pruritic dermatoses, 90% were found to be vitamin D deficient (Goetz, 2011).

Level 1 Fundamental Focused Interventions (all settings)

• Pruritus
• Malaise
• Prolonged bed rest. Refer to Disuse Syndrome.
• Fever. Refer to Ineffective Thermoregulation.

Reduce Pruritus and Promote Comfort

R:Pruritus can be triggered or worsened by negative feelings, such as stress or emotional excitation, including rage, fear, annoyance, and embarrassment, as well as other cognitive factors (Millington et al., 2018).

Maintain Hygiene without Producing Dry Skin

Encourage frequent baths:

• Use cool water when acceptable.
• Use mild soap (Castile, lanolin) or soap substitute (*Williams, 2009).

Prevent Excessive Dryness (*National Cancer Institute, 2011a)

• Lubricate skin with a moisturizer or emollients, unless contraindicated; pat on with hand or gauze.
• Apply ointments/lotions 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.
• Apply emollient creams or lotions at least 2 or 3 times daily and after bathing. Recommended emollient creams include Eucerin or Nivea or lotions, such as Lubriderm, Alpha Keri, or Nivea.
• Avoid skin products containing alcohol and menthol.
• Avoid petroleum products on irradiated skin.

R:Petrolatum is poorly absorbed by irradiated skin and is not easily removed. A thick layer could produce an undesired bolus effect when applied within a radiation treatment field.

• Limit bathing to a half hour daily or every other day.
• Add oil at the end of a bath or add a colloidal oatmeal treatment early to the bath.
• Avoid topical agents, including talcum powders, perfumed powders, bubble baths, and cornstarch.

R:They can irritate the skin and cause pruritus.

• Use of cornstarch to areas of irradiated skin following bathing.

R:"Cornstarch has been an acceptable intervention for pruritus associated with dry desquamation related to radiation therapy, but it should not be applied to moist skin surfaces, areas with hair, sebaceous glands, skin folds, or areas close to mucosal surfaces" (National Cancer Institute, 2011a).

• Avoid underarm deodorants or antiperspirants during radiation therapy.

R:Agents with metal ions (i.e., talcum and aluminum used in antiperspirants) enhance skin reactions during external beam radiation therapy and should be avoided throughout the course of radiation therapy.

• Apply lubrication after bath, before skin is dry, to encourage moisture retention.
• Apply wet dressings continuously or intermittently. Provide 20- to 30-minute tub soaks of 32° to 38°F; water can contain oatmeal powder, Aveeno, cornstarch, or baking soda.

R:Hydration will relieve itching and remove crusts and exudates.

• Avoid excessive warmth or dryness; create a humid environment (e.g., humidifier).

R: "Heat increases cutaneous blood flow and may enhance itching. Heat also lowers humidity, and skin loses moisture when the relative humidity is less than 40%. A cool, humid environment may reverse these processes" (*National Cancer Institute, 2011a).

• Avoid perfumes, cosmetics, deodorants, rough fabrics, fatigue, stress, and monotony (lack of distractions) (Yarbro, Wujcik, & Gobel, 2018).

R:Pruritus is aggravated by conditions that stimulate nerve endings.

• Advise against scratching; explain the scratch-itch-scratch cycle.

R:The scratch-itch-scratch cycle. Itch produces scratching, which increases inflammation and causes excitation of nerve fibers, leading to more itching and scratching (Norris, 2019).

• Teach to apply a cool washcloth or ice over the site may be useful. Firm pressure at the site of itching, at a site contralateral to the site of itching, and at acupressure points may break the neural pathway.

R:These techniques can break the stimulation of the neural pathway (scratch-itch-scratch) (*National Cancer Institute, 2011a).

• Use mitts (or cotton socks), if necessary, on children and confused adults.
• Maintain trimmed nails to prevent injury; file after trimming.

R:Anything that scratches the skin will stimulate itching.

• Avoid excessive warmth or dryness, perfumes, cosmetics, deodorants, rough fabrics, fatigue, stress, and monotony (lack of distractions) (*Thorns & Edmonds, 2000; Yarbro, Wujcik, & Gobel, 2018).
• Proceed with health teaching, when indicated.
• Explain causes of pruritus and possible prevention methods.
• Explain factors that increase symptoms (e.g., low humidity, heat).
• Wash clothes in a mild detergent, and put through a second rinse cycle to reduce residue; avoid use of fabric softeners (Dreft, Purex). Could also add 1 tsp. of white vinegar/per quart of water to rinse water (*National Cancer Institute, 2011a).
• Prevent excessive warmth by the 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 the skin.
• Use frequent, thin applications of ointment, rather than one thick application.

R:Residue left by detergents and other washing additives, e.g., softeners, antistatic, may aggravate pruritus. Detergent residue can be neutralized by the addition of vinegar (1 teaspoon per quart of water) to rinse water.

• Advise about exposure to sun and heat and protective products.
• Teach the individual to avoid fabrics that irritate skin (wool, coarse textures).

Level 2 Extended Interventions (pediatrics) (Hockenberry, Rodgers, & Wilson, 2018)

• Explain to children why they should not scratch. Teach them to pat instead of scratching or to press or (if permitted) put a cool cloth on the area that itches.
• Dress child in long sleeves, long pants, or a one-piece outfit to prevent scratching.
• Avoid overdressing child, which will increase warmth.
• Give child a tepid bath before bedtime; add 2 cups of cornstarch to bath water.
  • Bathe the child regularly, use moisturizers, and practice good skin care techniques.
  • Keep the child's room cool at night to prevent sweating that can irritate the skin.
  • Avoid harsh soaps.
• Make sure the child's fingernails are short, as scratching may contribute to an infection.
• Use lubricating lotions at least once a day.
• Apply Caladryl lotion to weeping pruritic lesions; apply with small paintbrush.
• Use cotton blankets or sheets next to skin.
• Remove furry toys that may increase lint and irritate skin = pruritus.