Skill 10-1

Promoting Patient Comfort

The nurse can promote increased comfort and relieve patient discomfort and pain through various interventions and therapies. Interventions can include comfort measures, emotional support, nonpharmacologic interventions, and the administration of analgesics and/or other medications to remove or alter the intensity of painful stimuli. Nonpharmacologic methods of comfort and pain management can diminish the emotional components of pain, strengthen coping abilities, give patients a sense of control, contribute to pain relief, decrease fatigue, and promote sleep (Bauldoff et al., 2020; Georga et al., 2019; Kiley et al., 2018; Labus et al., 2019). The Joint Commission (2018) supports the use of nonpharmacologic and nonopioid interventions for pain management, identifying that the use of nonopioid treatment options may be helpful in eliminating or reducing the need for/use of opioid analgesics. Refer as well to the Evidence for Practice display at the end of this skill.

The following skill identifies potential interventions to address discomfort and pain. The interventions are listed sequentially for teaching purposes; the order is not sequential and should be adjusted based on patient assessment and nursing judgment. Not every intervention discussed will be appropriate for every patient. Additional interventions for discomfort and pain are discussed in other chapters. Refer to Chapter 5 for nursing skills related to administering medications for pain relief. The application of heat or cold therapy is discussed in Chapter 8. Chapter 9 provides details related to patient positioning to promote patient comfort.

Delegation Considerations

The assessment of a patient's pain is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, some or all of the parts of assessment of a patient's pain may be delegated to licensed practical/vocational nurses (LPN/LVNs). The use of nonpharmacologic interventions related to patient comfort may be delegated to AP as well as to LPN/LVNs. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Pain assessment tool and pain scale
Oral hygiene supplies
Nonsterile gloves, if necessary
Additional PPE, as indicated
Additional supplies, depending on specific intervention utilized

Assessment

Review the patient's health record and plan of care for information about the patient's status and contraindications to any of the potential interventions. Inquire about any allergies. Assess the patient's level of discomfort. Assess the patient's pain using an appropriate assessment tool and pain scale. Assess the characteristics of any pain and for other symptoms that often occur with the pain, such as headache or restlessness. Ask the patient what interventions have and have not been successful in the past to promote comfort and relieve pain. Assess the patient's vital signs. Check the patient's medication administration record for the time an analgesic was last administered. Assess cultural beliefs and influences related to the pain experience. Assess the patient's response to a particular intervention to evaluate effectiveness and presence of adverse effects. Refer to assessment details included in Fundamentals Review 10-1, 10-2, 10-3, and 10-4.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Acute pain
Chronic pain
Discomfort

Outcome Identification and Planning

The expected outcome to achieve is that the patient experiences relief from discomfort and/or pain without adverse effect. Other outcomes that may be appropriate include that the patient experiences decreased anxiety and improved relaxation; is able to participate in activities of daily living (ADLs); and verbalizes an understanding of, and satisfaction with, the comfort and pain management plan.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Discuss pain with the patient, acknowledging that the patient's pain exists. Discuss the patient's expectations for comfort and pain relief. Explain how interventions to address discomfort, pain management therapies, and pain medications work together to alleviate discomfort and provide pain relief. Encourage the patient to collaborate in the plan of care to address discomfort and for pain relief.	These measures promote a collaborative relationship in which the patient is treated with respect. Pain discussion and patient involvement strengthen the nurse-patient relationship and promote pain relief (Taylor et al., 2023). Explanation encourages patient understanding and engagement and reduces apprehension.
4. Assess the patient's level of comfort and pain using an appropriate assessment tool and measurement scale (see Fundamentals Review 10-1 through 10-4).	Accurate assessment is necessary to guide treatment/relief interventions and evaluate the effectiveness of pain control measures.
5. Provide pharmacologic interventions, if indicated and prescribed.	Analgesics and adjuvant drugs reduce perception of pain and alter responses to discomfort.
6. Adjust the patient's environment to promote comfort.	The environment can improve or detract from the patient's sense of well-being and can be a source of stimulation that aggravates pain and reduces comfort.
a. Adjust and maintain the room temperature per the patient's preference.	A too-warm or too-cool environment can be a source of stimulation that aggravates pain and reduces comfort.
b. Reduce harsh lighting but provide adequate lighting per the patient's preference.	Harsh lighting can be a source of stimulation that aggravates pain and reduces comfort.
c. Reduce harsh and unnecessary noise. Avoid having conversations immediately outside the patient's room.	Noise, including talking, can be a source of stimuli that aggravates pain and reduces comfort.
d. Close the room door and/or curtain whenever possible.	Closing the door or curtain provides privacy and reduces noise and other extraneous stimuli that may aggravate pain and reduce comfort (Aparício & Panin, 2020; Goeren et al., 2018.)
e. Provide good ventilation in the patient's room. Reduce unpleasant odors by promptly emptying bedpans, urinals, and emesis basins after use. Remove trash and laundry promptly.	Odors can be a source of stimuli that aggravate pain and reduce comfort.
7. Prevent unnecessary interruptions and coordinate patient activities to group activities together. Allow for and plan rest periods without disturbance.	Frequent interruptions and disturbances for assessment or treatment can be a source of stimuli that aggravate pain and reduce comfort. Fatigue reduces tolerance for pain and can increase the pain experience.
8. Assist the patient to change position frequently. Assist the patient to a comfortable position, maintaining good alignment and supporting extremities, as needed. Raise the head of the bed, as appropriate (see Chapter 9 for more information on positioning).	Positioning in proper alignment with supports ensures that the patient will be able to maintain the desired position and reduces pressure.
9. Provide oral hygiene as often as necessary (every 1 or 2 hours if necessary) to keep the mouth and mucous membranes clean and moist. This is especially important for patients who cannot drink or are not permitted fluids by mouth (see Chapter 7 for additional information about oral care).	Moisture helps maintain the integrity of mucous membranes. Dry mucous membranes can be a source of stimuli that aggravate pain and reduce comfort.
10. Ensure the availability of appropriate fluids for drinking, unless contraindicated. Make sure the patient's water pitcher or a water bottle is filled and within reach. Have other fluids of the patient's choice available.	Thirst and dry mucous membranes can be sources of stimuli that reduce comfort and aggravate pain.
11. Remove physical situations that might cause discomfort.
a. Change soiled and/or wet dressings; replace soiled and/or wet bed linens.	Moisture can cause discomfort and irritation to skin.
b. Smooth wrinkles in bed linens.	Wrinkled bed linens apply pressure to skin and can cause discomfort and irritation to skin.
c. Ensure patient is not lying or sitting on tubes, tubing, wires, or other equipment.	Tubing and equipment apply pressure to skin and can cause discomfort and irritation to skin.
12. Assist the patient, as necessary, with ambulation, and active or passive range-of-motion exercises, as appropriate (see Chapter 9 for more information about activity).	Activity prevents stiffness and loss of mobility, which can reduce comfort and aggravate pain.
13. Assess the patient's spiritual needs related to the pain experience. Ask the patient if they would like a spiritual counselor to visit.	Some people's spiritual beliefs facilitate positive coping with the effects of illness, including pain (Minton et al., 2018; Taylor et al., 2023).
14. Consider the use of distraction. Distraction requires the patient to focus on something other than the discomfort and pain.	Focused attention on pain may increase the perception of pain. Preoccupation with other things has been observed to decrease the experience of discomfort and pain. Distraction requires the patient to focus attention on something other than the pain. It is not entirely clear whether distraction raises the threshold of pain or increases pain tolerance (Taylor et al., 2023).
a. Have the patient recall a pleasant experience or focus attention on an enjoyable experience.
b. Offer age or developmentally appropriate games, toys, books, audiobooks, access to television, and/or videos, or other items of interest to the patient.
c. Encourage the patient to hold or stroke a loved person, pet, or toy.
d. Offer access to music the patient prefers. Turn on the music when pain begins, or before anticipated painful stimuli. The patient can close their eyes and concentrate on listening. Raising or lowering the volume as pain increases or decreases can be helpful.
15. Consider the use of guided imagery.	Guided imagery incorporates mental images to enhance an overall sense of well-being and to promote relaxation, helping the patient to gradually become less aware of the discomfort or pain (Krau, 2020; Taylor et al., 2023). Positive emotions evoked by the image help reduce the pain experience and improve patient comfort (Krau, 2020).
a. Help the patient to identify a scene or experience that the patient describes as happy, pleasant, or peaceful.
b. Encourage the patient to begin with several minutes of focused breathing, relaxation, or meditation (refer to specific information in Steps 16 and 17).
c. Help the patient concentrate on the peaceful, pleasant image.
d. If indicated, read a description of the identified scene or experience, using a soothing, soft voice.
e. Encourage the patient to concentrate on the details of the image, such as its sight, sounds, smells, tastes, and touch.
16. Consider the use of relaxation activities, such as deep breathing.	Relaxation techniques reduce skeletal muscle tension and lessen anxiety, both of which can reduce comfort and aggravate pain. Relaxation can also be a distraction, providing help in reducing the pain experience (Helming et al., 2021; Taylor et al., 2023; Ward, 2016).
a. Have the patient sit or recline comfortably and place their hands on their stomach. Ask them to close their eyes.
b. Ask the patient to mentally count to maintain a comfortable rate and rhythm. Have the patient inhale slowly and deeply while letting the abdomen expand as much as possible. Have the patient hold their breath for a few seconds.
c. Tell the patient to exhale slowly through the mouth, blowing through puckered lips. Have the patient continue to count to maintain comfortable rate and rhythm, concentrating on the rise and fall of the abdomen.
d. When the patient's abdomen feels empty, have the patient begin again with a deep inhalation.
e. Encourage patient to practice at least twice a day, for 10 minutes, and then use the technique, as needed, to assist with pain management.
17. Consider the use of relaxation activities, such as progressive muscle relaxation.	Relaxation techniques reduce skeletal muscle tension and lessen anxiety, both of which can reduce comfort and aggravate pain. Relaxation can also be a distraction, providing help in reducing the pain experience (Hasanpour-Dehkordi et al., 2019; Taylor et al., 2023; Ward, 2016).
a. Assist the patient to a comfortable position.
b. Direct the patient to focus on a particular muscle group. Start with the muscles of the jaw, then repeat with the muscles of the neck, shoulder, upper and lower arm, hand, abdomen, buttocks, thigh, lower leg, and foot.
c. Ask the patient to tighten the muscle group and note the sensation that the tightened muscles produce. After 5 to 7 seconds, tell the patient to relax the muscles all at once and concentrate on the sensation of the relaxed state, noting the difference in feeling in the muscles when contracted and relaxed.
d. Have the patient continue to tighten-hold-relax each muscle group until the entire body has been covered.
e. Encourage the patient to practice at least twice a day, for 10 minutes, and then use the technique, as needed, to assist with pain management.
18. Consider the use of cutaneous stimulation, such as the intermittent application of heat or cold, or both (see Chapter 8 for additional information on heat and cold therapy).	Heat helps relieve pain by stimulating specific nerve fibers, closing the gate that allows the transmission of pain stimuli to centers in the brain. Heat accelerates the inflammatory response to promote healing and reduces muscle tension to promote relaxation and help to relieve muscle spasms and joint stiffness. Cold reduces blood flow to tissues and decreases the local release of pain-producing substances, such as histamine, serotonin, and bradykinin, and reduces the formation of edema and inflammation.
	Cold reduces muscle spasm, alters tissue sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli (Taylor et al., 2023).
19. Consider the use of cutaneous stimulation, such as massage (see Skill 10-2).	Cutaneous stimulation techniques stimulate the skin's surface, closing the gating mechanism in the spinal cord, decreasing the number of pain impulses that reach the brain for perception. Massage has been suggested as having positive effects on patient outcomes, including promotion of sleep, fatigue (Ahmadidarrehsima et al., 2018), and reduction of anxiety (Ayik & Özden, 2018; Hsu et al., 2019; Jagan et al., 2019; Kudo & Sasaki, 2020).
20. Discuss consideration of consultation with a nurse trained in healing touch (HT)/therapeutic touch (TT) with the patient.	HT and TT are complementary health approaches that have proved valuable as an adjunct to traditional health interventions (Taylor et al., 2023). Studies have indicated that HT and TT are effective in reducing pain and anxiety and promoting patient comfort and health (Bagci & Yucel, 2020; Davis et al., 2020; Weaver, 2017). TT has been suggested as a means to address comfort during end-of-life care (Tabatabaee et al., 2016).
21. Discuss the potential for use of cutaneous stimulation, such as transcutaneous electrical nerve stimulation (TENS) or electrical muscle stimulation (EMS, ESTIM, E-Stim) with the patient and the health care team (see Skill 10-3).	Cutaneous stimulation techniques stimulate the skin's surface, closing the gating mechanism in the spinal cord, decreasing the number of pain impulses that reach the brain for perception.
22. Discuss the potential for use of other complementary health approaches (CHA) and integrative health care IH) interventions, such as aromatherapy, humor, mindfulness, acupuncture and dry needling, hypnosis, biofeedback, or animal-assisted activities (AAA) and animal-assisted intervention (AAI), with the patient and the health care team.	CHA and IH can be practiced in all health care settings a part of a holistic pain management strategy (Ayik & Özden, 2018; Jaruzel et al., 2019; Sandvik et al., 2020; Taylor et al., 2023).
23. Remove equipment and return patient to a position of comfort. Remove gloves, if used. Perform hand hygiene. Raise the side rail and lower the bed.	Equipment removal and repositioning promote patient comfort. Removing gloves properly and hand hygiene reduce the risk for infection transmission and contamination of other items. Lowering the bed promotes patient safety.
24. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
25. Evaluate the patient's response to interventions. Reassess level of discomfort or pain using original assessment tools. Reassess and alter care plan, as appropriate.	Evaluation allows for individualization of plan of care and promotes optimal patient comfort.

Evaluation

The expected outcomes have been met when the patient experiences relief from discomfort and/or pain without adverse effect; experiences decreased anxiety and improved relaxation; is able to participate in activities of daily living (ADLs); and verbalizes an understanding of, and satisfaction with, the comfort and pain management plan.

Documentation

Guidelines

Document pain assessment and other significant assessments. Document comfort and pain relief therapies used and patient responses. Record CHA and IH interventions to consider, if appropriate. Document reassessment of comfort and pain after interventions, at an appropriate interval, based on specific interventions used.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient reports or assessment reveals, ineffective/or lack of pain relief: Reassess pain and evaluate response to implemented therapies. Implement additional or alternate interventions until desired level of comfort is achieved.
Intervention increases patient discomfort or pain: Immediately stop intervention. Document intervention used and the effect. Communicate changes in the patient's condition to the health care team, as appropriate. Revise plan of care, noting adverse effect of intervention, so other caregivers avoid using same intervention.

Special Considerations

General Considerations

The use of complementary, integrative, and adjunct therapies is often a “try-and-see” process. Many interventions can be tried to achieve the best combination for a particular patient. People respond to pain differently; what works for one person may not help another.

Infant and Child Considerations

Assessment, measurement, and treatment of discomfort and pain in infants and children frequently involve the use of more than one technique. Pain scales have been developed for various pediatric populations (Wrona & Czarnecki, 2021). Communication and collaboration with parents, guardians, caregivers, or other people important to the patient is vital for accurate pediatric pain assessment and management (Kyle & Carman, 2021; Taylor et al., 2023).
Nonpharmacologic therapies can be very beneficial in decreasing acute and chronic pain, as well as pain related to procedures in infants and children (Kyle & Carman, 2021) and should be tailored to the developmental level of the child and their individual needs (Wrona & Czarnecki, 2021).
Age-appropriate nonpharmacological pain management interventions include:
- Infants: breastfeeding, oral sucrose, non-nutritive sucking, swaddling (Ceylan & Bolɩşɩk, 2018) and rocking the infant back and forth (swaying) (Wrona & Czarnecki, 2021)
- Toddlers: bubbles, toys, books, secure hugging by a parent (comfort hold) (Wrona & Czarnecki, 2021)
- School-age children: secure hugging by a parent during procedures (comfort hold), video games, toys, books, bubbles (Wrona & Czarnecki, 2021)

Older Adult Considerations

In addition to medical problems, poor positioning or posture, inactivity, emotional issues, and adverse drug reactions could be at the root of new or worsened pain. Improving these underlying factors is the first step in pain management (Eliopoulos, 2018, p. 170).
Pain negatively impacts on the emotional well-being, functional ability, sleep, coping, and resources of older adults. Although pain is not a normal part of aging, pain occurs secondary to many chronic illnesses that are present in older adults (Taylor et al., 2023).
Assessment of pain in the older adult can be problematic. Vision or hearing impairments may influence the assessment format. Multiple-drug regimens that are common in older people can also affect reliable reporting of pain. Many older adults view pain as a forecast of serious illness or death, thus are reluctant to admit its occurrence or report it. Boredom, loneliness, and depression may affect an older adult's perception and report of pain (Taylor et al., 2023).

EVIDENCE FOR PRACTICE

Nonpharmacological Therapies and Patient Comfort

Complementary health approaches are increasingly being integrated into patient care plans related to the management of pain. Nurses can implement nonpharmacologic therapies in all health care settings as part of a holistic pain management strategy (Taylor et al., 2023).

Related Evidence

Kovach, C. R., Putz, M., Guslek, B., & McInnes, R. (2019). Do warmed blankets change pain, agitation, mood or analgesic use among nursing home residents? Pain Management Nursing, 20(6), 526-531. https://doi.org/10.1016/j.pmn.2019.07.002

The purpose of this quality improvement project was to describe the use of warmed blankets in a nursing home setting and examine if the use was associated with changes in pain, agitation, mood, or analgesic use. The project was conducted at one urban, 160-bed, skilled long-term care facility in Wisconsin. Residents of the facility who were not using a transdermal drug or who did not have an acute injury, acute inflammatory process, multiple sclerosis, open skin wound, or any other condition that might be worsened by superficial heat were eligible to receive a warming blanket (n = 141). Warmed blankets were unfolded and placed over residents with pain, agitation, or thermal discomfort. Short-term changes in pain and agitation from baseline (prior to application of the blanket) to 30 minutes after application of the blanket and to the next shift after application were examined using the Revised FACES Pain Scale for participants who could self-report, the PAINAD for those who could not self-report, and the Brief Agitation Rating Scale. Comparisons were made from 1 month before to 1 month after warmed blanket use between those receiving the warmed blanket and a randomly selected group who did not receive a warmed blanket. Long-term outcomes measured included the number of pain complaints, pain severity, prn analgesic use, agitation, and mood. There were statistically significant decreases in both pain level and agitation among baseline, 20 minutes after application, and the subsequent shift assessments (P ; .001). There were also long-term changes in the number of pain complaints (P ; .040), severity of pain complaints (P ; .009), and as-needed analgesic use (P ; .011). There were no statistically significant differences between the treated group and comparison group on any long-term measures. The authors concluded that warmed blankets have potential for reducing pain, short-term agitation, and discomfort in residents of long-term care facilities and should be considered to increase resident comfort.

Relevance to Nursing Practice

Nurses should collaborate with the health care team to integrate nonpharmacological therapies to address patient comfort and pain management. Nurses should consider individual patient preferences when planning interventions for the management of pain and consider complementary health approaches to provide holistic care to their patients.

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Skill 10-1

EVIDENCE FOR PRACTICE