NURSING DIAGNOSIS--ALTERATION IN COMFORT-PAIN: VALIDATION OF THE DEFINING CHARACTERISTICS

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Authors Tidwell, Irene Donna, 1956-

Publisher The University of Arizona.

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1329501

Tidwell, Irene Donna

NURSING DIAGNOSIS-ALTERATION IN COMFORT-PAIN: VALIDATION THE DEFINING CHARACTERISTICS

The University of Arizona M.S. 1986

University Microfilms

International 300 N. Zeeb Road, Ann Arbor, Ml 48106

Copyright 1986

by

Tidwell, Irene Donna

All Rights Reserved

NURSING DIAGNOSIS — ALTERATION IN COMFORT-PAIN:

VALIDATION OF THE DEFINING CHARACTERISTICS

by

Irene Donna Tidwell

A Thesis Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements For the Degree of

MASTER OF SCIENCE

In the Graduate College

THE UNIVERSITY OF ARIZONA

1 9 8 6

Copyright 1986 Irene Donna Tidwell

STATEMENT BY AUTHOR

This thesis has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.

Brief quotations from this thesis are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the copyright holder.

SIGNED: JluiAJL

APPROVAL BY THESIS DIRECTOR

This thesis has been approved on the date shown below:

Suzanne van ort Date Associate Professor of Nursing

DEDICATION

Completing a Master's program and thesis is one of the most

enlightening journeys of my life in learning about myself, others, and

the world around me. The journey was filled with discovery, wonder, and

the freedom to grow. The journey could not have been made without the

encouragement of loved ones or friends. I dedicate this thesis to:

My parents, Mr. and Mrs. Carlos R. Tldwell, Sr.

My humorous brother, Carlos R. Tidwell Jr.

Dearest life-long friends, Karl Mann

Marion Davis

Anne Caton

and last, but not least, to my beloved husband and soul-mate, Steven

Dell Larson.

iii

ACKNOWLEDGMENTS

I extend my warmest appreciation to the members of my thesis

committee, Dr. Suzanne Van Ort, Dr. Anne Woodtli, and Dr. Rose Gerber.

Their support, patience, and encouragement were essential for my growth

and completion of this journey of discovery. A very special thank-you

to Dr. Suzanne Van Ort, Chairperson of my committee, who steadfastly

supported and prodded me, without whom this study may not have been

realized.

A sincere thanks to Dr. Alice Longman, who sparked my quest and

supported my ideas, without whom the journey may have never begun.

A deepest gratitude is given to my parents for sacrificing in

order to provide me the opportunity for a college education.

Finally, to the professional men and women of the Air Force at

Davis-Monthan USAF Hospital, whose flexibility and assistance, provided

a conducive atmosphere for this journey to occur. I thank and salute

you.

iv

TABLE OF CONTENTS

Page

LIST OF TABLES viii

LIST OF ILLUSTRATIONS ix

ABSTRACT x

1. INTRODUCTION 1

Significance of the Research 3 Purpose of Research ....... ... 5 Assumptions 6 Summary 6

2. CONCEPTUAL FRAMEWORK AND REVIEW OF LITERATURE 8

Validation of the Nursing Diagnosis Model 8 A Retrospective Validation Study Design 10 The Conceptual Model for Alteration in

Comfort-Pain 11 Nursing Diagnosis 13 Defining Characteristics 15 The Nursing Diagnosis of Alteration

in Comfort-Pain 15 Defining Characteristics of Alteration

in Comfort-Pain 20 The General Defining Characteristics:

Critical Cluster 23 Actual Defining Characteristics,

Critical Cluster 31 Final Defining Characteristics,

Critical Cluster 31 Actual Nursing Diagnosis, Alteration

in Comfort-Pain 32 The Relationship Among the Components 32 Summary 33

v

vi

TABLE OF CONTENTS—Continued

Page

3. METHODOLOGY 34

Research Design ." 34 Study Setting and Sample 35 Protection of Human Subjects 36 Data Collection Plan 36

Record Review and Instrument ... 36 Reliability and Validity 39 Data Analysis Plan 40 Summary 41

4. PRESENTATION OF THE DATA 42

Results Related to ACPAT Instrumentation 42 ACPAT Validity 42 ACPAT Interrater Reliability 43 Summary of Revised ACPAT 45

Results Related to the Use of the Preprinted Nursing Admission Notes 45

Negations of Defining Characteristics of Pain ... 46 Demographic Characteristics of the Sample 48 Defining Characteristics of Pain . 52 Total NANDA Characteristics 55 Total Non-NANDA Characteristics 55 Categories of Defining Characteristics 55 Results Related to the Research Questions 59 Summary 60

5. DISCUSSION j. IMPLICATIONS AND RECOMMENDATIONS 65

The Sample and Instrument 65 Discussion Related to Research Questions 66

Question #1 66 Question #2 . 69

Source of Potential Error 70 Recommendations for Further Study ......... 71 Implications for Nursing 71 Summary 74

TABLE OF CONTENTS—Continued

vii

Page

APPENDIX A: UNIVERSITY OF ARIZONA COLLEGE OF NURSING HUMAN SUBJECTS APPROVAL 75

APPENDIX B: VETERANS' ADMINISTRATION RESEARCH AND DEVELOPMENT COMMITTEE APPROVAL 77

APPENDIX C: NURSING PREPRINTED ADMISSION NOTE STANDARD FORM 507 79

APPENDIX D: NURSING PREPRINTED ADMISSION NOTE STANDARD FORM 509 82

APPENDIX E: ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL 85

APPENDIX F: REVISED ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL 90

REFERENCES 95

LIST OF TABLES

Page

1. Uses of Nursing Diagnoses (ND) and Defining Characteristics (DC) by Nursing Note Format as Identified from Record Review 47

2. Marital Status by Age Group of the Sample Population as Identified from the Record Review 49

3. Racial-Ethnic Background by Age Group of the Sample Population as Identified from the Record Review ... 50

4. Nursing Unit by Primary Medical Diagnosis Categories of the Sample Population as Identified from the Record Review 51

5. Defining Characteristics of Pain Present in Nurses Notes as Identified from Record Review 53

6. The Total NANDA Characteristics by Defining Characteristic as Identified by Record Review 56

7. Non-NANDA Defining Characteristics by Defining Characteristic as Identified from Record Review 57

8. Category of Defining Characteristics Number per Record as Identified from Record Review 58

9. Final Critical Cluster of Signs and Symptoms Present in Ten Percent or More of the Records 61

10. The Total NANDA Characteristics by Number Per Record as Identified from Record Review 62

11. Total Non-NANDA Defining Characteristics by Number Per Record as Identified from Record Review 63

viii

LIST OF ILLUSTRATIONS

Page Figure

1. Alteration in Comfort-Pain Model 12

2. Comfort, Alteration in: Pain Defining Characteristics Characteristics and Etiology 24

3. Major Classes and Subclasses of Word Descriptors 26

ix

ABSTRACT

A retrospective validation study was designed to identify and

refine the defining characteristics of the nursing diagnosis, Altera­

tion in Comfort-Pain as set by the National Conference of Nursing Diag­

noses (NANDA). A retrospective record study of 100 records was con­

ducted at a 350 bed hospital in a southwestern city. The Alteration in

Comfort-Pain Assessment Tool (ACPAT) was developed and assessed content

validity. The final critical cluster of defining characteristics, which

refined and expanded the NANDA list, was composed of verbal descrip­

tors, guarded behavior, distraction behavior, and facial mask of pain.

The primary verbal defining characteristic was "verbalizes pain medica­

tion" or patient's request for pain medication. The need for improved

documentation in nurse's notes and the implementation of an ongoing

quality assessment program were identified as issues to be considered

in future studies.

x

CHAPTER 1

INTRODUCTION

The purpose of this study was to identify the cluster of signs

and symptoms describing the nursing diagnosis Alteration in Comfort-

Pain. Nurses have always collected information about patients/clients

to use as a basis for determining patient needs for care (Gordon,

1982). The process of collecting and categorizing information is called

nursing diagnosis (Gordon, 1982). Assessment is the first step of the

nursing diagnosis process. The outcome of the assessment phase is the

formulation of the diagnosis statement. The nursing diagnosis statement

was described by Mundlnger and Jauron (1975) as comprised of two-parts:

the problem definition and the defining characteristics. The problem

definition or the unhealthful response of the client, was the first

part of the statement. The second part identified the factor(s) that

can contribute to the problem. The contributing factors were comprised

of the defining characteristics and etiologies of the problem.

Alteration in Comfort-Pain is defined "as a state in which the

individual experiences an uncomfortable sensation in response to a

noxious stimulus" (Carpenito, 1983, p. 112). The International

Association for the Study of Pain (IASP) defined pain as "an unpleasant

sensory experience associated with actual or potential tissue damage

..." (IASP, p. 250). The definition of pain is applicable to physical

1

2

etiologies, such as local tissue reactions, and to psychological

factors affecting the threshold of pain, such as anxiety. Thus the

cluster of signs and symptoms of the nursing diagnosis Alteration in

Comfort-Pain were composed of defining characteristics and etiologies

of pain.

In general, there was an agreement by North American Nursing

Diagnosis Association (NANDA), that the nursing diagnosis included:

assessment; a summarized statement of the conclusion derived from the

assessment; and identification of a cluster of signs and symptoms

(Henderson, 1978). Assessment included a systematic process of data

collection and analysis which required a synthesis of a cluster of

signs and symptoms identifying the patient's state which is the problem

statement (Mundinger & Jauron, 1975; Gebbie & Lavin, 1976; Gordon,

1982; Roy, 1982; Shoemaker, 1984). Nursing assessment provided the

defining characteristics leading to the nursing problem statement or

nursing diagnosis. If the selected defining characteristics truly

reflected areas of nursing concern, the nursing diagnoses should have

been readily identifiable (Feild, 1979).

Because of the multidimensional nature of pain, a need exists

to: develop accurate assessment tools for pain; validate the defining

characteristics of pain; and to develop different interventions for

different etiologies of pain (Mahoney, 1977; Kim, 1980; McGuire, 1985).

Further study in theory, assessment ability, nursing interventions, and

diagnosis is necessary in order to provide quality care for patients in

pain. In the literature, pain was consistently approached from the

nurse's perspective as a symptom that requires nursing management to be

controlled (McCorkle, 1977; Mehta, 1977; Breindel & Boyle, 1979;

McCaffery, 1979; Ryan, 1980). In response to an identified lack of

research on Alteration in Comfort-Pain, the present study was designed

to contribute to the quality of patient care by verifying, through a

descriptive study, the defining characteristics of pain as recorded by

nurses in an acute hospital setting.

Significance of the Research

There have been six National Conferences on the classification

of nursing diagnoses, which generated forty-two accepted nursing

diagnoses (Kim & Moritz, 1982). Most of the nursing diagnoses were

developed inductively. A great need exists to deductively verify the

inductively-formed nursing diagnoses and their defining characteris­

tics. Research is needed to determine which defining characteristics

are critical to each nursing diagnosis (Williams, 1980). The critical

cluster of defining characteristics was defined as "those characteris­

tics which must be present in order for the nursing diagnosis to be

made" (Moritz, 1982, p. 56). To date, little research has been com­

pleted to verify the defining characteristics of nursing diagnoses

(Kim, 1982). The present study attempted to validate deductively the

critical cluster of defining characteristics of Alteration in Comfort-

Pain. To validate deductively a nursing diagnosis is complementary to

the utilization of the inductive approach for the development of this

diagnosis - Alteration in Comfort-Pain.

4

Pain is a common symptom of the majority of patients. Many

times pain will bring a patient to the physician initially. A diagnos­

tic procedure may result in pain. Correcting an illness through surgery

results in pain. A. chronic illness often results in intermittent or

constant pain. As a result, the nursing diagnosis Alteration in

Comfort-Pain is a widely applicable diagnosis, which is frequently used

by nurses.

The classification of nursing diagnoses is imperative to the

building of theory and applying theory to practice. Classification

promotes a common frame of reference, a system suitable for computeriza­

tion, clinical investigations and research (Roy, 1975; Gordon, 1982;

Carpenito, 1983; Shoemaker, 1984). Nursing diagnosis could influence

the quality of nursing practice by clearly defining the scope of nur­

sing accountability, and enhancing responsibility and identity (Feild,

1979). A diagnostic classification stimulates several areas of nursing

research. For example, research is needed to expand the number of nur­

sing diagnoses, validate the diagnoses in clinical settings, and

validate critical characteristics of a nursing diagnosis (Kritek, 1979,

1985; Gordon & Sweeney, 1979; Shamansky & Yanni, 1983). Further, clas­

sification of nursing diagnoses promotes a common frame of reference, a

system suitable for computerization, clinical investigations and

research (Roy, 1975; Gordon, 1982; Carpenito, 1983; Shoemaker, 1984).

To promote a common frame of reference, Gordon (1982) suggested

a need to standardize the nursing diagnoses into the problem-etiology-

signs and symptoms (PES) format. The problem was a concise statement of

the client's existing or potential health problem. The etiology

included environmental, sociological, spiritual, psychological,

physiological, and any other factors contributing to the health

problem. The signs and symptoms were the characteristics that reflect

the existence of the health problem (Price, 1980). The PES format was

accepted and used by the National Group for the Classification of

Nursing Diagnosis to describe a nursing diagnosis (Lunney, 1982).

The results of standardization and classification of nursing

diagnoses enabled the nursing diagnostic process to become an essential

part of the nursing process. With a clearer definition of diagnosis,

the result was a clarification of independent components of nursing

practice (Carpenito, 1983). Clarification of the nursing diagnoses pro­

vided more accountability for nurses in the legal arena and differenti­

ations of nursing from other professions. Autonomous use of nursing

diagnoses increases nurses' rights and responsibilities (Lash, 1978).

Purpose of Research

The purpose of this study was to retrospectively identify the

defining characteristics of Alteration in Comfort-Pain in a population

of adult patients for whom nurses documented a pain experience during

hospitalization.

The specific purpose of the study was to answer the following

questions:

6

1. Which signs and symptoms of Alteration in Comfort-Pain composed

the critical cluster of defining characteristics for the nur­

sing diagnosis?

2. Secondly, given a client presenting the signs and symptoms of

Alteration in Comfort-Pain, what did nurses identify as the

defining characteristics of the nursing diagnosis Alteration in

Comfort-Pain?

This study endeavored to identify the critical cluster of

defining characteristics of the nursing diagnosis Alteration in

Comfort-Pain. The critical cluster was identified descriptively through

a deductive process. A second focus of this study endeavored to

determine what cues nurses used to identify the diagnosis, Alteration

in Comfort-Pain.

Assumptions

Two assumptions were inherent in this study:

1. Nurses accurately reported the defining characteristics.

2. Defining characteristics of pain reported by the nurse were

valid and representative of the patient.

Summary

Introduction to the problem, significance of the research, and

purpose of the research were presented in this chapter. Alteration in

Comfort-Pain is a widely applicable nursing diagnosis. Validation of

its defining characteristics was necessary in order to ensure correct

identification of the diagnosis and appropriate nursing interventions.

The two research questions were:

1. Which signs and symptoms of Alteration in Comfort-Pain composed

the critical cluster of defining characteristics for the nur­

sing diagnosis?

2. Given a client presenting the signs and symptoms of Alteration

in Comfort-Pain, what did nurses identify for the presence of

the nursing diagnosis Alteration in Comfort-Pain?

Development of the diagnosis, Alteration in Comfort-Pain, would

promote improvement in nursing practice, as well as nursing account­

ability and autonomy. Above all, development of Alteration in Comfort-

Pain would improve the assessment and diagnostic process, and would

assist in the development of nursing interventions for patients in

pain.

CHAPTER 2

CONCEPTUAL FRAMEWORK AND REVIEW OF LITERATURE

The prevalence of pain in patients and how pain was clearly a

domain of nursing assessment, diagnosis, and intervention was presented

in Chapter One. The nursing process begins with assessment, and diag­

nosing is the outcome of assessment. The nursing diagnosis and its

defining characteristics are important for establishing nursing

accountability, autonomy, and high quality of care. There is a great

need for research to validate defining characteristic of nursing diag­

noses. Specifically, this study validated the defining characteristics

of the nursing diagnosis Alteration in Comfort-Pain. Therefore, the

nursing diagnosis and Alteration in Comfort-Pain formed the focal con­

cepts in the conceptual model in this study. A combination of a

modified validation model and a retrospective study design was the

framework for studying the defining characteristics and nursing

diagnosis of Alteration in Comfort-Pain in the clinical setting. Before

discussing the retrospective model for this study, a discussion of

validation of the nursing diagnosis is presented.

Validation of the Nursing Diagnosis Model

Defining characteristics can be described statistically (Brown,

1974). Purushotham (1971, p. 46) stated "nursing diagnosis was defined

as a phrase or a term which was the synthesis of a cluster of empirical

3

9

indicators describing behavioral characteristics of man". Because

defining characteristics could be statistically studied in the clinical

setting, several models have been developed to validate nursing

diagnoses (Gordon, 1985). In this study a retrospective validation

model was utilized. A retrospective validation was conducted of the

NANDA characteristics. In addition the defining characteristics not

identified in NANDA listing were identified.

Several research studies attempted to validate defining

characteristics of nursing diagnoses. Kim and others (1984) completed a

research study to clinically validate cardiovascular nursing diagnoses.

The authors reported the average number of nursing diagnoses per

patient listed by staff nurses was 3.76 and by clinical specialists,

5.32. The average number of defining characteristics per nursing

diagnosis by staff nurses was 2.38 and by clinical specialists, 3.11. A

total of 601 diagnoses were reported by staff nurses for 158 patients

with 41 different nursing diagnosis. The 10 most frequently used

nursing diagnoses appeared to have been chosen appropriately from the

appropriate cues. This study demonstrated a high level of clinical

relevance between cues from the patient assessments and the use of the

nursing diagnosis to plan the nursing treatment of patients.

Another study by Balistriere and Jiricka (1984) validated the

defining characteristics of the nursing diagnosis, role disturbance.

The authors found that six of the signs and symptoms were found in 50

percent or more of the cases. In 1982, Nlcoletti, Reitz, and Gordon

attempted to identify critical defining characteristics of actual and

10

potential parenting alterations. A pattern of high frequency of

empirical indicators emerged.

Research into the defining characteristics of nursing

diagnoses, particularly the nursing diagnosis of pain, is a relatively

new focus for nursing. The need to systematically validate the defining

characteristics of pain is important. Because of the multi-dimensions

of pain, the defining characteristics of pain are difficult to

recognize in patients. In fact, after an extensive literature review,

this researcher could not find any research studies validating the

defining characteristics of the nursing diagnosis Alteration in

Comfort-Pain. Deductive research of defining characteristics of pain

and nurse's perception of defining characteristics is needed.

A Retrospective Validation Study Design

A way to deductively identify defining characteristics of pain

and nurses' perception of defining characteristics of pain is through a

retrospective study design. A retrospective validation study involves

clinical identification and validation of a nursing diagnosis through

retrospective record review (Gordon, 1985). In the past, retrospective

record review (RRR) has been used in large studies to verify the use of

NANDA nursing diagnoses in the clinical setting. For example, Leslie's

(1982) study, which was comprised of professional nursing staff record­

ings of 1521 diagnoses in 210 clients' charts, validated the use of

NANDA nursing diagnoses. Sweeney and Gordon (1983) followed a similar

method and validated the use of NANDA nursing diagnoses. Thirty-one

percent of the diagnoses were identical in wording to the NANDA nursing

11

diagnoses. Another study by Nicoletti, Reitz, and Gordon (1982) valid­

ated a frequently used nursing diagnosis Alteration in Parenting, for

signs and symptoms congruent with the NANDA defining characteristics

for potential for alteration in parenting. No retrospective validation

studies of the nursing diagnosis Alteration in Comfort-Pain were found

in the available literature.

The Conceptual Model for Alteration in Comfort-Pain

The concepts of nursing diagnosis and Alteration in Comfort-

Pain are the basis for the conceptual model in the present study

(Figure 1). The model presented is similar to and adapted from the

model developed by MacKenzie (1984) for validating the nursing

diagnosis of actual fluid volume excess. Each component of the

Alteration in Comfort-Pain model was defined as follows:

Defining Characteristics: The signs and symptoms which have a 60%

frequency of occurrence (Williams, 1980).

Nursing Diagnosis: "Nursing diagnoses are responses to actual or

potential health problems which nurses by virtue of their

education and experience are capable and licensed to treat"

(Gordon, 1976, p. 1299).

Defining Characteristics of Alteration in Comfort-Pain: Signs and

symptoms identifying the patient in pain, which have a 60%

frequency of occurrence.

12

Defining Nursing Diagnosis

Defining Characteristics of Alteration in Comfort-Pain

Nursing Diagnosis Alteration in Comfort-Pain

General Defining Characteristics: Critical Cluster

Actual Defining Characteristics: Critical Cluster

Final Defining Characteristics: Critical Cluster

Actual Nursing Diagnosis of Alteration in Comfort-Pain

Figure 1. Alteration in Comfort-Pain Model

(Adapted and modified from MacKenzie, 1984)

13

Nursing Diagnosis Alteration in Comfort-Pain: "A state in which the

individual experiences an uncomfortable sensation in response

to a noxious stimulus" (Carpenito, 1983, p. 112).

General Defining Characteristic, Critical Cluster: Signs and symptoms

from NANDA and literature review, which have a 60% frequency

of occurrence and must be present to formulate the nursing

diagnosis of pain.

Actual Defining Characteristic, Critical Cluster: Signs and symptoms

after the study was conducted which have a 60% frequency of

occurrence and must be present to formulate the nursing diag­

nosis of pain.

Final Defining Characteristics, Critical Cluster: The comparison and

synthesis of the General Defining Characteristic, critical

cluster and Actual Defining Characteristics, critical cluster.

The Actual Nursing Diagnosis Alteration in Comfort-Pain: The nursing

diagnosis Alteration in Comfort-Pain formulated from the Final

Defining Characteristics, critical cluster.

All of the positive relationships of the levels were derived from the

literature. Each component of the model and related literature will be

reviewed. Finally, the relationships among the components will be

discussed.

Nursing Diagnosis

The two components of the construct level of the model to be

discussed were the defining characteristics and the nursing diagnosis.

Definitions of nursing diagnosis abound in the literature. Komorita

14

(1963, p. 84) described nursing diagnosis as "a conclusion based on

scientific determination of an individual's nursing needs, resulting

from critical analysis of his behavior, the nature of his illness, and

numerous other factors which affect his condition". Gordon (1976, p.

1299) stated "nursing, diagnosis, or clinical diagnosis made by

professional nurses, describes actual or potential health problems

which nurses by virtue of their education and experience are capable

and licensed to treat". Gebbie and Lavin (1976, p. 114) describe

nursing diagnosis as "the judgment or conclusion resulting from a

recognition of a pattern derived from a nursing investigation of the

patient". According to Roy (1982, p. 219), "Nursing diagnosis is a

concise phrase or term summarizing a cluster of empirical indicators

representing patterns of unitary man". "A nursing diagnosis is a

statement of a potential or actual altered health status of a

client(s), which is derived from nursing assessment and which requires

interventions from the domain of nursing" is how Edel (1982, p. 6)

defined nursing diagnosis. Shoemaker proposed the most recent

definition to include qualities of a professional. Shoemaker (1984)

stated that a nursing diagnosis is a clinical judgment derived from a

data base through a systematic process of data collection and analysis,

which provided prescriptions for therapy, and that the nurse was held

accountable. And the diagnosis concisely stated would include the

etiology of the condition when known (Shoemaker, 1984).

In summary, the diagnosis can be defined as a systematic

process of data collection and analysis involving a synthesis of signs

15

and symptoms identifying the patient's state (Mundinger & Jauron, 1975;

Gebbie & Lavin, 1976; Gordon, 1982; Roy, 1982; Shoemaker, 1984).

Defining Characteristics

Since the nursing diagnosis can be defined as a systematic

process of data collection and analysis involving a synthesis of signs

and symptoms identifying the patient's state, the synthesis of signs

and symptoms is inherent in the definition of nursing diagnosis. The

synthesis of signs and symptoms consistently and frequently occurs for

the particular nursing diagnosis. Another name for this grouping of

highly frequent occurring signs and symptoms is the defining

characteristics (Price, 1980; Williams, 1980). Data Clustering is the

grouping of these signs and symptoms from the nursing health history,

physical examination, and laboratory resulted as part of the process of

determining the nursing diagnosis (Carnevali, 1983; Potter, 1985). A

review of the previous definitions of nursing diagnoses indicates that

defining characteristics were consistently inherent in the definitions.

Therefore, the defining characteristics were positively related to the

identification of the nursing diagnosis (Figure 1).

The Nursing Diagnosis of Alteration in Comfort-Pain

At the concept level of the model were the defining character­

istics of Alteration in Comfort-Pain and the nursing diagnosis Altera­

tion in Comfort-Pain. The nursing diagnosis Alteration in Comfort-Pain

can be attributed to a multitude of variables of physiological and

16

psychological processes as evidenced in the definitions of pain, the

defining characteristics of pain, and the etiologies of pain.

Pain is a complex phenomenon and does not have one clear

definition. Physiologic, psychologic, social, cultural, and spiritual

variables interact to produce the experience reported by the individual

as pain (Donovan, 1982). Sternbach (1968, p. 12) called pain "1) a

personal, private sensation of hurt; 2) a harmful stimulus which

signals current or impending tissue damage; 3) a pattern of responses

which operate to protect the organism from harm." The International

Association for the Study of Pain (IASP) (1979, p. 259) defined it as

"an unpleasant sensory and emotional experience associated with actual

or potential tissue damage, or described in terms of such damage."

Melzack and Wall (1982) stated that the definition of pain cannot be

formulated yet. They viewed the word "painj' as representing a category

of experiences, signifying a multitude of different, unique experiences

having different causes. The characteristics of pain were different

qualities varying along a number of sensory and affective dimensions

(Melzack & Wall, 1982).

Other authors tended to focus more on a operational definition.

Carpenito (1983, p. 112) defined pain as "a state in which the

individual experiences an uncomfortable sensation in response to a

noxious stimulus". Another operational definition, "pain is whatever he

says it is" is presented by McCaffery (1968, p. 95; 1972, p. 8; 1979,

p. 11). Furthermore, pain was defined in terms of a time frame. Acute

pain was pain that lasted from one second to as long as six months.

17

Pain subsided with healing or when a stimulus was removed (Marino,

1981; Carpenito, 1983; Mclntire & Cloppa, 1984). Acute pain may be

caused by a surgical incision or a fractured arm. Chronic pain is

persistent or intermittent pain that lasts for more than six months

(Carpenito, 1983; Jones, 1984; Noville, 1984; Taylor, 1984). Chronic

pain could be caused by terminal or chronic illnesses such as cancer or

chronic obstructive pulmonary disease.

Campbell (1978) listed over 35 nursing diagnoses of pain in

1978. A few of the nursing diagnoses were bone pain, muscle spasm,

phantom pain, and constrictive pain.

On the other hand, Carpenito developed the nursing diagnosis

according to the temporal definitions of acute and chronic pain and the

differing defining characteristics under each. Alteration in Comfort-

Acute pain was defined as "pain that can last from one second to as

long as six months" (Carpenito, 1983, p. 117). The defining

characteristics included: person reports pain; fear of pain; inability

to concentrate; guarded position; muscle spasm; increase pulse, blood

pressure, and respirations; evidence of inflammation, rubbing or

pulling of body part, and tense body posture. Alteration in Comfort-

Chronic Pain was defined as "persistent or intermittent pain that lasts

for more than six months" (Carpenito, 1983, p. 122). The defining

characteristics included: person reports following signs have existed

for more than six months - pain, discomfort, anger, frustration,

depression; facial mask of pain; anorexia; insomnia; guarded movement;

18

muscle spasm, redness, heat; color changes in the affected area; and

reflex abnormalities.

Gordon did not distinguish chronic from acute pain, but she did

point out that the autonomic nervous system response could only be

applied to acute pain. Gordon defined Alteration in Comfort-Pain as

"verbal report and presence of indicators of severe discomfort"

(Gordon, 1984, p. 182). She listed the following defining character­

istics; communication (verbal or coded) or pain descriptors; guarded

behavior - protective; self-focusing; narrowed focus (altered time

perception); withdrawal from social contact; impaired thought process;

distraction behavior (moaning, crying, pacing, seeking out other people

and/or activities); facial mask of pain (eyes lack of luster, "beaten

look", fixed or scattered movement, grimace); alteration in muscle

tone; and autonomic response not seen in chronic or stable pain such as

diaphoresis,'changes in blood pressure, pulse rate, or respirations and

pupillary dilatation (Gordon, 1984).

In a nursing diagnosis statement "the first part of the diagno­

sis communicates the behaviors that could be improved through nursing

assistance; the second part identifies what factors must be worked with

to accomplish improved patient condition" (Lunney, 1982, p. 456).

Because the second part is developed from the etiology and defining

characteristics, assessment becomes important. Because of the many

possible variables associated with pain, systematic and accurate

assessment is imperative for the individual in pain in order to provide

the correct nursing treatment to help alleviate the pain (Anderson,

19

1982; Bagley, 1982; Rankin, 1984; McGuire, 1984). Assessment provides

the cues to determine the etiology and characteristics of the

diagnosis.

Mundinger and Jauron (1975) also suggested that the statements

be joined by the words "related to". This prevents legal problems in

establishing a causal relationship and provides flexibility for

altering the statement if there is a change in one part (Mahoney,

1977). An example of such diagnosis is pain related to decreased oxygen

to cells after short periods of activity. Diagnoses could also indicate

potential or tentative unhealthful responses. In this way preventive

measure could be indicated, as well as showing the need for additional

information to verify or refute the suggested response (Mahoney, 1977).

In summary, the second part of the nursing diagnosis became important

in determining treatment of a patient with pain and describing the type

of pain which can be verified or refuted later.

To promote a common frame of reference, Gordon (1982) suggested

a need to standardize the nursing diagnoses into the problem-etiology-

signs and symptoms (PES) format. The problem was a concise statement of

the client's existing or potential health problems. The etiology

included environmental, sociological, spiritual, psychological,

physiological, and any other factors contributing to the health

problem. The signs and symptoms were the characteristics that reflect

the existence of the health problem (Price, 1980). The PES format was

accepted and used by the National Group for the Classification of

Nursing Diagnosis to describe a nursing diagnosis (Lunney, 1982).

20

The nursing diagnosis Alteration in Comfort-Pain was the

accepted nursing diagnosis of the Fifth National Conference of Classi­

fication of Nursing Diagnoses in 1984. The accepted defining character­

istics were: communication (verbal or coded) of pain descriptors -

communicating; guarding behavior, protective-moving; narrowed focus

(altered time perception, withdrawal from social contact, impaired

thought process)-perceiving; and alteration in muscle tone (may span

from listless to rigid) - moving (Approved Nursing Diagnoses, 1984).

Defining Characteristics of Alteration in Comfort-Pain

Defining characteristics are composed of signs and symptoms

which have high frequency of occurrence at the time the nursing diagno­

sis is formulated. The defining characteristics can be independent or

interdependent. Interdependent defining characteristics are those

clinical indicators requiring assessment from other disciplines.

Independent defining characteristics are those signs and symptoms which

are independently assessed and accounted for by nurses. The defining

characteristics of Alteration in Comfort-Pain, are independent and

could be accounted for by nurses.

The defining characteristics of pain from the pathophysiolog­

ical viewpoint can be explained by the physiology of nerve conduction

and the gate control theory. The description of nerve fibers and their

conduction (Goodman, 1983; Donovan & Girton, 1984; Potter, 1985)

focuses on two types of nerve fibers which conduct painful stimuli:

large diameter myelinated A-delta fibers and the small unmyelinated

C-fibers. The A-delta fibers carry sharp localized pain along with

temperature and touch at fast rates. The C fibers relay dull diffuse

pain along sympathetic impulses at slow rates. The result is an initial

sharp sensation at time of injury with a diffuse ache after injury.

The gate control theory proposed by Melzack and Wall (1965) is

the most frequently presented theory in the pain literature (Kim, 1980;

Donovan, 1982; Atkinson, 1985; Potter, 1985b). According to this theory

the transmission of potentially painful impulses could be altered by a

gating mechanism located in the spinal cord as well as by activity in

higher central nervous system structures. The perception and reaction

to painful stimulus result from interplay between substantia gelantin-

osa (SG) cells, central transmission cells (T-cells), and afferent

fibers in the dorsal column within the spinal cord and the brain stem.

The cells within the (SG) in the dorsal horn of the spinal cord are the

first system. The second system involves the (T cells) in the dorsal

horn and the third system included the afferent fibers in the dorsal

column of the cord. The transmission of a painful stimuli could follow

this sequence: The painful response traveled through the afferent A

fibers or C fibers to the dorsal horn. At the dorsal horn, the impulses

encountered a gate, the SG cells. The SG cells could be open, partially

open, or closed. If the gate was closed, pain impulses could not pro­

ceed. If the gate was partially open, the pain impulses stimulate the T

cells in the dorsal horn. The impulses ascend the spinal cord to the

brain, and pain perception results unless the central nervous system

(CNS) feedback mechanism halts the impulse transmission. Gate position

22

depends on whether A fibers or C fibers impulses predominate. When

small C fibers predominated, T cells were activated and the pain

message ascended to the brain. Apparently T cells must receive a

certain level of C fiber stimulation before they become active. The

higher CNS structures could modulate pain by influencing the T-cell

activity. These structures control such factors as attention, emotion,

and memory (Melzack & Wall, 1965; McCaffery, 1979; Armstrong, 1980;

Kim, 1980; Donovan, 1982; Potter, 1985). Because of these interplaying

factors, an individual has a unique perception of pain (Melzack, 1973).

Merskey (1980) and Sternbach (1974) described the types of pain

and how they were transmitted. The five types of pain were: superficial

or cutaneous, deep visceral, referred, radiating, and phantom limb

pain. Superficial or cutaneous pain resulted from stimulation of the

skin and was sharp, localized, and of short duration. Deep visceral

pain resulted from stimulation of the internal organs. The pain was

diffuse, lasted longer, and radiated in several directions. Referred

pain was a common phenomenon in visceral pain. Sensory neurons from the

affected organ entered the same spinal segment as neurons from other

areas. Hence the brain perceived pain in unaffected areas. Radiating

pain was a sensation extending from the initial site of injury to

another part of the body. An example was low back pain radiating down

the leg from sciatic nerve irritation. Phantom limb pain was an

abnormal sensation or feeling that a limb still remained, even though

it was amputated.

23

The General Defining Characteristics: Critical Cluster

The Third and Fourth Nursing Diagnosis Conference formulated

and approved the nursing diagnosis, Alteration in Comfort-Pain and its

eight groupings of defining characteristics (Kim, 1982). In the Third

and Fourth Nursing Diagnosis Conference, Alteration in Comfort-Pain was

listed in Chapter Seven, entitled "Approved Nursing Diagnoses" (Kim,

1982) (Figure 2). In the Fifth Nursing Diagnosis Conference, Alteration

in Comfort-Pain was listed briefly as a diagnosis which needed further

study in research (Kim, 1984). The General Defining Characteristics,

Critical Cluster, can be described through a PES schema by Gordon

represented in the Third and Fourth Nursing Diagnosis Conferences. The

description of the General Defining Characteristics included subjective

and objective characteristics and pain etiologies.

The subjective characteristics are comprised of communication

descriptors. The subjective characteristic may be the critical defining

characteristic. The communication descriptors of pain can be verbal or

coded descriptors.

In Melzack's study using the McGill Pain Questionnaire (1965),

he found that patients categorized subjective pain experiences into

three major classes of word descriptors. The three major classes were

sensory, affective, and evaluative. Sensory descriptors included words

that described experience in terms like temporal, spatial, pressure, or

thermal. Affective descriptors described qualities of tension, fear,

and other autonomic properties which affect the pain experience. Evalu­

ative words described the overall intensity of the total pain

24

COMFORT, ALTERATION IN: PAIN

Definition

Pain is what the patient says it is (operational definition).

Defining Characteristics

Subjective

Communication of pain descriptors (verbal or coded)

ing, pacing, seeking out other people and/or activities, rest­lessness) Facial mask of pain (eyes lack luster, "beaten look", fixed or scattered movement, grimace) Alteration in muscle tone (may span from listless to rigid) Autonomic responses not seen in chronic stable pain (diaphoresis, blood pressure and pulse rate change, pupillary dilatation,

increased or decreased respiratory rate)

Objective

Guarded behavior, protective Self-focusing ' Narrowed focus (altered time perception, withdrawal from social contact, impaired thought process) Distraction behavior (moaning, cry-

Etiology

Injuring agents Biological, chemical, physical Psychological

Figure 2. Comfort, Alteration In: Pain Defining Characteristics and Etiology

(From Kim & Moritz, 1982, p. 285)

experience (Melzack, 1965). In another study Melzack and Torgerson

(1971) studied the significance of words to describing pain in the

three major classes. Certain words had 90 to 100 percent agreement by

100 subjects to the three major classes and their subclasses (Figure

3).

"Failure on the part of the nurse to acknowledge that she is

accountable for effective communication may be one of the main reasons

for failure to achieve optimal pain relief" (Sofaer, 1983, p. 32).

Sofaer went on to say that patients may not hear what was being said to

them because of pain. Difficulties arose when the patient's verbal

expression of pain did not appear to be consistent with his other

behavior. Many nurses relied only on physiological indicators of pain.

Verbal responses could include sighing, moaning, screaming, crying,

repetition of words or phrases, as well as statements of pain (Johnson,

1977). Verbal communication was the only available means of determining

the subjective aspects of the pain experience. "Pain discussion is the

only method available to the clinician to attempt to grasp the full

implication of the pain experience for the patient" (Johnson, 1977, p.

140).

Another factor which made pain assessment difficult was the

physiological, cognitive/affective, and behavioral interplay. Early

life experiences affected pain experiences. Pain signals, behavioral

and oral, varied in relation to culture, developmental age, previous

experiences, and cognitive skills (Dugan, 1983). Pain tolerance could

be reduced by voluntarily submitting to pain, reducing anxiety, by

motivation, and by reducing decreasing sensory input (Sternbach, 1968;

26

Sensory Affective Evaluative

Temporal-pounding, pulsing, throbbing

Spatial-shooting, darting, spreading, radiating

Mild Punctate Pressure-piercing, stabbing

Incisive Pressure-cutting

Constrictive Pressure-cramping, pressing, crushing

Traction Pressure-pulling, tugging, wrenching

Thermal-burning, scalding

Brightness-smarting, tingling

Dullness-aching numbing

Tension-fatiguing, dragging, tiring

Autonomic-sickening, nauseating, suffocating

Fear-frightful, Punishment-grueling, killing, torturing

Agonizing Annoying Intolerable Horrible Miserable Troublesome Unbearable

Figure 3. Major Classes and Subclasses of Word Descriptors

(From Melzack & Torgerson, 1971)

27

Feldman, 1983). Personal Internal and external coping strategies

affected an individual's efforts to deal with or recover from a painful

state (Dugan, 1983). Cultural perceptions could influence a person's

view of pain in many ways. Three nursing textbooks (Nursing Series Now,

1985; Potter, 1985; Atkinson, 1985) discussed the defining character­

istics of pain in different cultures. In most cultures, girls were more

free to openly express pain than boys. Individuals from the Italian

culture tended to have a low pain tolerance, may cry and gesture with

body movement, and did not like to complain to family but liked them

around as a distraction. On the other hand, individuals from the Jewish

culture had a low tolerance to pain, gave dramatic accounts of pain,

and cried and moaned to bring family around for sympathy. While a

patient's culture established overall standards for behavior, his

family established values by emphasizing or de-emphasizing various

cultural and social standards.

The next characteristics of pain to occur were responses of the

sympathetic autonomic nervous system (SNS). Guarded and protective

behavioral responses were one of the first SNS responses occurring

after recognition of pain. These responses were part of the involuntary

response in acute pain, which were relatively the same for most

individuals. The model proposed by Melzack and Wall (1965) identified

seven components of the response to acute pain. This model was accepted

in nursing textbooks (Potter, 1985; Atkinson, 1985). Physiologically,

the startle response, flexion reflex, and activation of the autonomic

nervous system occurred to initiate the acute response. Postural

28

readjustment, that was moving away from the source of pain if external,

and to more comfort if internal, and vocalization, were behavioral

responses that occurred simultaneously with the reflexive components.

Cognitive/affective input was required for evaluation of the experience

and prediction of the consequences. The last component of Melzack and

Wall's model, a behavioral one, was a reduction in the sensory and

affective components of pain. The physiological response was previously

explained in detail at the beginning of the discussion on defining

characteristics.

Sympathetic response include increased respiratory rate,

increased heart rate, peripheral vasoconstriction/elevation of the

blood pressure, increased blood glucose, diaphoresis, increased muscle

tension, dilation of the pupils, and decreased gastric motility.

Behaviors may have represented an increase in body action like rubbing

or supporting the painful area. Frequent change in body position, and

walking or pacing, were other examples (Johnson, 1977). Sometimes

behaviors represented a reduction in activity. These actions included

resting an extremity, protecting an area from any stimulation, and

decreasing body movement by lying quietly (Johnson, 1977). Facial mask

of pain had the following characteristics: pinched features, a knotted

brow, dilated pupils, facial grimaces, eyes lack luster, "beaten look",

or fixed or scattered movements (Johnson, 1977; Atkinson, 1985).

A self-focusing or a narrowed focus occurred as a coping method

(Copp, 1974; Mehta, 1976; Taylor, 1984). Variation of the method

included counting, deep thinking/visualization, and separation.

29

Counting occurred when the patient counting anything and everything

available. Patients also performed mathematical problems, letter

arrangements, and other types of counting. Prayer, imagery, concentrat­

ing, finding hidden designs in objects, focusing on lights, shadows,

and other mental exercises were methods of deep thinking or visualiza­

tion. Deliberate attempts to separate mind and body, such as day

dreaming and self hypnosis were termed separation.

Distraction behavior was any behavior which helped the patient

avoid thinking about his/her pain. Patients smoked, sought out others,

talked in stream-of-consciousness, and took any other action to

distract their thoughts of pain (Johnson, 1977; Copp, 1974).

Gordon's PES format (1982) stressed the importance of including

etiology as part of the diagnostic statement. Etiology became a part of

the diagnostic statement through the use of the words "related to".

Identifying the etiology of pain in the nursing diagnosis directed and

planned the nursing interventions to relieve or increase the comfort of

the patient (Potter, 1985; Atkinson, 1985). Because pain was a complex

reaction of biological, chemical, physical, or psychological compo­

nents, one must have determined which one or more of these was affect­

ing the patient's discomfort. Biological/chemical/physical etiologies

were such events as insufficient blood flow in the arteries or a gas­

tric ulcer. Injuring agents were anything invasive to the body such as

a gunshot wound, swallowing a poison, or an infestation of parasites.

Psychological etiologies developed from emotional and thought pro­

30

cesses. Examples were psychosomatic symptoms, anxiety, depression, and

psychosis (Donovan & Girten, 1984; Yasko, 1983).

Guyton (1971) had a good description for the sources of pain

and how the sources affect sensory aspects. The source of pain deter­

mined many aspects of sensory characteristics of pain. Cutaneous, deep

somatic, and viscera were the three general pain sources. Cutaneous

pain was from superficial structures like skin and subcutaneous tis­

sues, which were well localized and sharp. Deep somatic pain originated

from bone, nerve, muscle, and other tissues supporting these struc­

tures. Deep somatic structures, that were highly innervated, were deep

fascia, tendons, ligaments, joints, periosteum of bone, blood vessels,

and nerves. Skeletal muscle was sensitive to stretching and ischemia.

Deep pain was felt as three-dimensional, in comparison to superficial

pain, which was linear. Visceral pain originated from body organs

located in the trunk. Visceral pain was often accompanied by referred

pain to bony surface cutaneous areas. Cardiac pain was a primary

example in that chest pain sometimes radiated down the left arm.

In summary, defining characteristics of pain could be

subjective or objective. Subjective characteristics were coded or

verbal descriptors. These descriptors were categorized into three

categories: sensory, affective, and evaluative. Intensities of pain

could be measured by instruments such as visual analogue or a numerical

scale. The subjective could be influenced by culture, family, and

psychological state of the individual. Indeed the individual's

perception and reaction to pain was influenced by all three. Objective

31

responses were guarded, self-focusing, and distractlve behaviors.

Facial mask of pain and change in muscle tone may accompany the

behavior. The etiology of pain must have been considered to provide a

supportive plan of intervention and is part of the nursing diagnosis

statement. So the defining characteristics, general critical cluster

were the signs, symptoms and etiology from NANDA and literature review

which have a 60% frequency of occurrence and must be present to

formulate the nursing diagnosis of pain.

Actual Defining Characteristics, Critical Cluster

Actual Defining Characteritics, Critical Cluster was composed

of the signs and symptoms in this study which had a 60 percent of fre­

quency occurrence. The signs and symptoms must have been present to

formulate the nursing diagnosis of pain.

Final Defining Characteristics, Critical Cluster

The Final Critical Cluster was the list of the characteristics

which occurred 60 percent or more of the time in both the General

Defining Characteristics Critical Cluster and the Actual Defining

Charactristic Critical Cluster. The Final Defining Characteristic,

Critical Cluster would be pertinent to formulate the Actual Nursing

Diagnosis, Alteration in Comfort-Pain.

32

Actual Nursing Diagnosis, Alteration in Comfort-Pain

The nursing diagnosis, Alteration in Comfort-Pain was

formulated from the comparison of Defining Characteristic, the general

critical cluster and the Actual Defining Characteristic, Critical

Cluster. The formulation of the nursing diagnosis was involved with the

frequency outcome of each critical defining characteristic as

identified from retrospective record review.

The Relationship Among the Components

The constructs of Defining Characteristics and Nursing

Diagnosis were expected to have a positive relationship based on

literature. At the concept level, the Defining Characteristics of

Alteration in Comfort-Pain had a positive relationship to the nursing

diagnosis Alteration in Comfort-Pain. At the operational level were the

Defining Characteristics, general critical cluster and Actual Defining

Characteristics, critical cluster, which were compared and synthesized.

The synthesis of the two defining characteristic, critical clusters

formulated the Final Defining Characteristic, Critical Cluster. The

Final Defining Characteristic, Critical Cluster formulated the basis

for the Actual Nursing Diagnosis Alteration in Comfort-Pain through the

diagnostic process. The relationship of the last four components was

the focus of the present study.

33

Summary

Chapter Two presented the conceptual framework and review of

the literature for the study of the Nursing Diagnosis, Alteration in

Comfort-Pain. The nursing diagnosis, derived through a systematic

collection and analysis of a patient, family, or community's state

resulting in a clinical judgment, provided the basis for the definitive

therapy for which the nurse was accountable. The present study was

designed to retrospectively validate the Actual Defining

Characteristics of Pain used by nurses in the clinical setting, and

compared the results with the present critical defining characteristics

determined by the National Conference of Nursing Diagnoses. The Final

Defining Characteristics, Critical Cluster resulted in the formulation

of the Actual nursing diagnosis Alteration in Comfort-Pain through the

nursing diagnostic process.

CHAPTER 3

METHODOLOGY

The study was designed to identify the critical defining

characteristic for the nursing diagnosis of Alteration in Comfort-Pain.

The research design, setting, sample, instrument, data collection

methods, and the data analysis plan are presented in this chapter.

Research Design

A descriptive and retrospective validation study design was

used to identify the critical cluster of defining characteristics of

pain that were used by nurses in the clinical setting. A retrospective

validation study involved clinical identification and validation of a

nursing diagnosis through retrospective record review (Gordon, 1985).

In the past, retrospective record review (RRR) has been used in larg'e

studies to verify the use of North American Nursing Diagnosis Associa­

tion (NANDA) nursing diagnoses in the clinical setting.

The methodology of this study was based on Dalton's (1985)

model in which Cardiac Output, Alterations In: Decreased, was validated

through retrospective validation. In the present study, data were

collected through the use of a data collection tool comprised of the

defining characteristics of Alteration in Comfort-Pain derived from

literature review and NANDA's listings. NANDA's listings and additional

34

35

characteristics identified in the literature review for validation in

the clinical setting were designated on the assessment tool.

Study Setting and Sample

A 350 bed hospital in a Southwestern city was the institution

used for this study. The hospital used problem oriented medical record

(POMR) format for charting. The institution employed registered nurses

who have diploma, associate degree and/or baccalaureate degree prepara­

tion in nursing. New staff nurses are routinely given an orientation to

nursing diagnosis and POMR charting. The staff must have passed a test

on nursing diagnosis and POMR charting prior to beginning patient care

on the units. The first six weeks, each new staff nurse worked with a

preceptor nurse, who instructed and evaluated the new staff nurse's

skills including the use of nursing diagnoses and POMR charting. The

Quality Assurance program provided unit audits to evaluate and ensure

that nurses document appropriately using the POMR format including

correct nursing diagnoses. If the nurses did not appropriately document

using the POMR format including the correct nursing diagnoses, the

feedback was reported back to the individual nurse.

For the present study, a sample of 100 records of male patients

discharged from January 1 to December 31, 1985, was obtained. A sample

of 100 records was chosen based on Dalton's study (1985). A male popu­

lation was chosen because the population at the hospital is predomi­

nantly male with few females admitted.

36

Protection of Human Subjects

The research study was approved by the Ethical Review Committee

of the College of Nursing (Appendix A). Confidentiality and anonymity

were assured. The data collection tool did not include patients' names

or the particular institution involved. The record number was a coded

number placed by and known only to the investigator. Permission to

conduct the study was obtained from the Hospital Medical Records

section and from the Research Committee at the clinical setting

(Appendix B).

Data Collection Plan

Record Review and Instrument

The chief of medical services required the medical records

staff obtain the records. Since the investigator could not pull the

records, a computer list of patient with the primary medical diagnosis

having the word "pain" was generated for discharges from January 1 to

December 31, 1985. The investigator then requested the patient records

in groups of 25 records. The medical records staff had two nights to

obtain the 25 records and place them in the record reading room on the

day the investigator specified. Therefore, only 25 records could be

reviewed daily Monday through Friday. The investigator reviewed 300

records before obtaining the one hundred records that constituted the

study sample. The investigator then placed the reviewed records into

the file bin for refiling.

37

Data were collected by the Investigator. Every discharged

patient record was reviewed for the diagnosis Alteration in Comfort-

Pain. Each record was reviewed for one nurse's note using the diagno­

sis, Alteration in Comfort-Pain. If there were more than one nursing

note on Alteration in Comfort-Pain in the record, only the first

nursing note using the diagnosis was chosen for review. The first

nurse's note was the admission note which followed one of two pre­

printed formats. Standard Form 507 (SF 507) had designated listings of

defining characteristics of pain, but did not have a space for assess­

ment of pain (Appendix C). In comparison, Standard Form 509 (SF 509),

using the subjective, objective, assessment and plan format, did not

always show documentation of defining characteristics (Appendix D).

The records in the sample were from medical or surgical units

including intermediate and intensive care units. The patient record was

the unit of analysis for the demographic data. Each defining character­

istic within each nursing note was the unit of analysis for the

descriptive data.

The data collection instrument, the Alteration in Comfort-Pain

Assessment Tool (ACPAT), was developed by the investigator from the

NANDA listing of defining characteristics of Alteration in Comfort-

Pain and literature review (see Appendix E). The first section of the

instrument was concerned with demographic data including age, marital

status, medical diagnosis, ethnic background, and nursing unit. Age,

marital status, and ethnic background were included because they may

have played a role in how the patient perceived his pain. Nursing units

38

were designated as S for surgical, M for medical, and I for intensive

and intermediate care settings. Marital status was designated as S for

single, M for married, W for widowed, and D for divorced. Ethnic

origins were designated as C for Caucasian, B for Black, A or Asian, I

for American Indian, and H for Hispanic. Medical diagnosis, the primary

diagnosis for the patient, was written in.

The second section of the ACPAT contained the items of defining

characteristics of pain directly from literature review and NANDA

listing. The starred items were the approved characteristics from the

NANDA listings. The NANDA categories were counted as a characteristic

only when nurses used the category as a characteristic, resulting in no

duplication of the defining characteristics. The characteristics under

each category were appropriate for that category. For example, the

autonomic response included increased heart rate, increased blood

pressure, and other associated autonomic responses.

Each column designates one record. The record was assigned a

number between one and 100. Hence, the record numbers with one to 100.

Each row represented a defining characteristic assigned a number from

characteristic, CI to C76. The blank rows thereafter were for other

characteristics not designated in the list and therefore needing to be

written in. The totals are the sum of the characteristics for each

record, each characteristic and each category.

39

Reliability and Validity

Interrater reliability in using the ACPAT instrument was

assessed. To estimate interrater reliability the investigator and one

trained nurse rater used the instrument independently on the same

record. The percent agreement was an exact agreement item by item and

not a summated score. Training of the rater is one setting was

accomplished by the primary investigator using the ACPAT and explaining

its use in relation to a record. The investigator explained by

demonstrating a step by step method with a sample record. Initial

interrater reliability was assessed for ten records which were not part

of the study sample. In one setting the trained rater examined ten

records using the ACPAT. Then the investigator examined the same ten

records in the same setting immediately after the trained nurse rater

using the ACPAT. Each item per item of defining characateristic of each

record was compared for agreement. The criterion of .80 was used for

interrater reliability. That is, eighty percent of the defining

characteristics of each rater must have agreed for the same record note

for each of the ten records.

Content validity was the sampling adequacy of the content used

on the Instrument (Kerlinger, 1973). It was the judgment, arrived by a

panel of experts on the content area, who judged the adequacy of the

items in the tool (Polit & Hungler, 1978). This instrument was given to

a panel of three experts who regularly cared for patients in pain. The

panel consisted of three nurses, each one Master's prepared with over

eight years of clinical experience in medical-surgical nursing. Each

40

member had experience dealing with patients in acute and chronic pain

and documenting pain with nursing diagnoses. Percent agreement among

the nurse experts was used. A criterion of .90 was preset for content

validity. Each expert was asked to judge each category as well as the

entire tool for adequacy of the content. This was performed by

answering the following questions: Does each item CI to C76 portray a

defining characteristic of Alteration in Comfort-Pain excluding the

demographic items? Each expert was to check yes or no to each charac­

teristics item on the content validity checklist. Each expert was to

check yes or no on the content validity of the tool as a whole. Two out

of the three must have said yes to be accepted. And two out of the

three must have said no to be rejected.

Data Analysis Plan

Descriptive analysis was used to analyze the demographic data

and the defining characteristics. Specifically, frequency distributions

were used to describe patient age, type of nursing unit, marital

status, ethnic origin, and medical diagnosis. Also frequency distribu­

tions were used to describe frequency of defining characteristic per

record/incident, most frequently occurring defining characteristics

identified by staff nurses, summary of national defining characteris­

tics as used by the staff nurses, and summary of non-national defining

characteristics as used by the staff nurses. All of the previous

studies chose the top ten most frequently occurring defining character­

istics to determine the critical cluster. The defining characteristics

41

of greatest frequency In 60 percent of the charts or greater was

considered the critical cluster in this study. If a defining character­

istic occurs one hundred percent of the time, then this researcher will

designate it as the defining critical characteristic.

Summary

The methodology for the study was described in Chapter Three.

The retrospective design, sample and setting, procedures for data

collection, and plan for data analysis were presented. The categories

of defining characteristics, A.CPAT instrument changes, demographic

characteristics of the sample, as well as explanation of unexpected

influences follow in the next chapter.

CHAPTER 4

PRESENTATION OF THE DATA

The plan for conducting the study was blueprinted in Chapter

Three. The focus of Chapter Four is to present results of the study in

frequency distribution and tabular format.

Results Related to ACPAT Instrumentation

ACPAT Validity

Before data collection was begun, content validity was assessed

by a separate review of three experts who regularly cared for patients

in pain. Each of the three experts was a registered nurse with a

Master's degree and more than eight years of clinical experience in

medical-surgical nursing. Each member had experience dealing with

patients in acute and chronic pain and documenting pain with nursing

diagnoses. A criterion of .90 was preset for content validity. Each

expert was asked to judge each category and characteristic as well as

the entire tool.

The experts agreed two out of the three on all items except for

C67, prayer. Two out of the three did not accept prayer as valid. In

the revised tool, C67 was deleted. (See Appendix F for the revised

ACPAT). The characteristics were renumbered after the deleted item. The

42

43

characteristics now numbered from CI to C75. All experts agreed that

the tool was valid as a whole.

ACPAT Interrater Reliability

To estimate interrater reliability the investigator and one

trained nurse rater used the instrument independently on the same

record and the same nurses' note. Initial interrater reliability was

assessed. Each item per item of defining characteristic of each record

was compared for agreement. The criterion of .80 was used for

interrater reliability.

Five records, item by item matched 100 percent between raters,

the other five records did not match item by item. The five non-

matching records agreed in the listed characteristics CI to C75, but

disagreed on all of the items written in as other characteristics. For

example, the trained rater would write in "Abdominal pain and gas". The

investigator for the same record and nursing note would write in:

"Abdominal pain-gas and severe pain". Three of the records did not have

any characteristics listed, but under the assessment wrote only the

nursing diagnosis, Alteration in Comfort-Pain. The investigator and

trained nurse rater also differed in how they wrote in the diagnosis,

e.g., "Impairment of Skin Integrity related to Alteration in Comfort

Pain" versus "Related to Actual Alteration in Comfort Pain". The fifty

percent agreement was definitely less than the eighty percent set in

the methodology.

The researcher decided to repeat the reliability at a different

institution because the researcher believed the reliability would

44

increase with better quality nursing documentation. Three of the

records at the original institution had no defining characteristics in

the nursing notes, but only the nursing diagnosis. At the original

institution, the nurses' notes were written by registered nurses

prepared at baccalaureate or associate degree levels and by licensed

practical nurses.

The better quality nursing documentation at the second

institution was projected because of an ongoing quality assurance

program. The nurses on the unit completed self-audits monthly, reported

their weaknesses at their monthly staff meetings, and developed

inservices to improve the weak areas. In this institution, the nurses

were all BSN prepared. In addition the charge nurses of each unit

audited other units' charts quarterly. These results were discussed at

a nursing quality assurance committee to disseminate feedback to all

units. The original institution did not have this elaborate quality

assurance auditing.

The percent agreement of the ten charts completed at the second

institution was 30 percent. Eight charts of the ten were in complete

agreement item by item between the investigator and the same trained

nurse rater. There was a marked decrease in the number of items written

in as other characteristics, and increase in the number of items marked

per record per nursing note. Out of ten records only two records had

written in items from the same nurse's notes and same two records. The

written items were different between investigator and trained nurse

rater. The trained nurse rater wrote "Pain with movement". The invest!-

45

gator wrote from the same record and nurse's note "unable to sleep due

to pain". All ten records agreed on the defining characteristics

checked within the list of CI to C75. The ACPAT met the criterion of

eighty percent within the defining characteristics listed, CI to C75,

but the reliability decreased with written-in items.

Summary of Revised ACPAT

In summary validity was improved by deleting C67 prayer and the

characteristics were renumbered from CI to C75. During the validity and

reliability test it was suggested that it would be easier to use the

tool if the verbal descriptors were rearranged in alphabetical order

(See Appendix F).

Results Related to the Use of the Preprinted Nursing Admission Notes

Since the criterion was set that the first nursing note with

the defining characteristics of pain and the nursing diagnosis, Alter­

ation in Comfort-Pain, would be used, the nursing admission note was

usually the first note. At least 63 percent of the nursing notes used

for each record were from preprinted admission nursing notes versus the

nursing progress note following a subjective, objective, assessment and

plan (SOAP) format. Two types of preprinted nurses' notes were used.

Eighteen percent or eighteen records used the standard form 507 (SF

507) (Appendix C). A large percentage of SF 507 were used in records,

but a prerequisite for choosing a record was that the nursing diagno­

sis, Alteration in Comfort-Pain must be stated. SF 507 does not desig­

nate a space to write assessments or nursing diagnoses. Only eighteen

46

SF 507 had the diagnosis written in the block "reason for hospitaliza­

tion". Forty-five percent or forty-five records used the standard form

509 (SF 509) (Appendix D). Thirty-seven percent or 37 records had the

nursing progress note (NPN) following a subjective, objective, assess­

ment and plan format. Table 1 presents a composite of the three types

of formats and conditions of nursing diagnosis and defining character­

istics. The nursing notes using the standard form 507 had at least two

or more defining characteristics of Alteration in Comfort-Pain due to

the format and the designated blocks for pain characteristics.

The nurses' note using standard form 509 had only one defining

characteristic of pain and the nursing diagnosis, Alteration in

Comfort-Pain. The previous condition occurred 84 percent of the time.

Seven nurses' notes of the 45 presented only the nursing diagnosis,

Alteration in Comfort-Pain.

The 37 nurses' progress notes using the non-preprinted format

had at least one defining characteristic and the nursing diagnosis,

Alteration in Comfort-Pain.

Negations of Defining Characteristics of Pain

Many of the nurses notes with the diagnosis, Alteration in

Comfort-Pain, had only negative defining characteristics of pain. Some

of the negative defining characteristics were "able to move more

freely", "no report of pain", or "no complaints". The ACPAT tool did

not consider these values.

Table 1. Uses of Nursing Diagnoses (ND) and Defining Characteristics (DC) by Nursing Note Format as Identified from Record Review

(N=100)

Conditions

Only ND 2 or more DC Both ND & DC Nursing Note Format n //%//%# #

SF 507 IS 18 100.0 18 100.0

SF 509 45 7 15.5 29 64.4 38 84.4

NPN 37 - - 17 45.9 37 100.0

Note: The condition only defining characteristic was omitted. The prerequisite for choosing a a record was the nursing diagnosis, Alteration in Comfot, was sated. Only 18 SF507 had the diagnosis written in the block "reason for hospitalization".

SF507 = Standard Form 507, Preprinted Nurses' Admission Note Form (See Appendix C)

SF509 = Standard Form 509, Preprinted Nurses' Admission Note Form (See Appendix D)

NPN = Nursing Progress

48

Demographic Characteristics of the Sample

The ages of the 100 male subjects ranged from 23 to 85 years

which is shown in Table 2. The mean age was 53 (s.d.=14.9); 52 percent

of the subjects were married. Twenty percent indicated a divorced

status; ten percent were single; and five percent were widowed.

The subjects' racial-ethnic background is presented in Table 3.

Eighty-four percent of the sample were of Caucasian racial-ethnic

background; ten were Hispanic; four were American Indian; and one

subject was a Black.

Fifty-five of the subjects were on surgical nursing units; 36

subjects were on medical nursing units; and eight subjects were on

intensive nursing units.

The subjects' placement in different nursing units described by

the primary medical diagnosis categories is presented in Table 4. The

primary medical diagnoses were divided into 9 categories. The categor­

ies were cardiac, cancer, gastrointestinal, neurological, orthopedic,

respiratory, trauma, urological, and other. The cardiac category (13

records) included diagnoses such as chest pain, angina, or coronary

bypass. The cancer category (8 records) included diagnoses which were

types of cancer such as leukemia, adenocarcinoma, lymphoma, cell carci­

noma or metastasized cancer. The gastrointestinal category (16 records)

was largely abdominal pain, peptic ulcer, or cholecystitis. The neuro­

logical category (3 records) included encephalopathy, cerebral aneurysm

or Parkinson's disease. The orthopedic category (33 record) included

primary medical diagnoses of low back pain, leg pain, arm pain,

Table 2. Marital Status by Age Group of the Sample Population as Identified from the Record Review

(N=100)

Marital Status

Single Married Widowed Div/Sep Missing Total Age Groups it % // % # % if % it % # %

20-29 3 3.0 2 2.0 - - - - 3 3.0 8 8.0

30-39 5 5.0 6 6.0 - - 8 8.0 - - 19 19.0

40-49 1 1.0 4 4.0 - - 1 1.0 - - 6 6.0

50-59 - - 11 11.0 - - 5 5.0 6 6.0 22 22.0

60-69 1 1.0 20 20.0 2 2.0 6 6.0 4 4.0 33 33.0

70-79 - - 9 9.0 2 2.0 - - - - 11 11.0

80-89 - - - - 1 1.0 - - - - 1 1.0

Total 10 10.0 52 52.0 5 5.0 20 20.0 13 13.0 100 100.0

Note: Mean age - 53.5 (s.d.=14.992) Marital Statu3is placed by age groups Age range = 23 to 85 because of Investigator's preference.

.> vO

Table 3. Racial-Ethnic Background by Age Groups of the Population as Identified from the Record Review

(N=100)

Racial-Ethnic Background American

Caucasian Hispanic Black Indian Total Age Groups # % # % # % # % i %

20-29 3 3.0 3 3.0 - - 2 2.0 8 8.0

30-39 18 18.0 - - 1 1.0 - - 19 19.0

40-49 6 6.0 - - - - - - 6 6.0

50-59 17 17.0 3 3.0 - - 1 1.0 21 21.0

60-69 29 29.0 4 4.0 - - - - 33 33.0

70-79 11 11.0 - - - - - - 11 11.0

80-89 - - - - - - 1 1.0 1 1.0

Total 84 84.0 10 10.0 1 1.0 4 4.0 99 99.0*

Note: *Total not 100% due to missing values. Caucasian, Black, American Indian are races. Hispanic is an ethnic group.

Arranged by age groups due to Investigator's preference.

Table 4. Nursing Unit by Primary Medical Diagnosis Categories of the Sample Population as Identified From the Record Review

(N=100)

Nursing Unit Medical Diagnoses Surgical Medical Intensive Total Categories # % # % # % # %

Orthopedic 20 20.0 13 13.0 — — 33 33.0

Gastrointestinal 10 10.0 4 4.0 1 1.0 15 15.0

Cardiac 4 4.0 5 5.0 4 4.0 13 13.0

Trauma 9 9.0 2 2.0 1 1.0 12 12.0

Cancer 2 2.0 6 6.0 - - 8 8.0

Other 3 3.0 3 3.0 1 1.0 7 7.0

Respiratory 1 1.0 2 2.0 1 1.0 4 4.0

Neurology 2 2.0 1 1.0 - - 3 3.0

Urology 3 3.0 - - - - 3 3.0

Total 55 55.0 36 36.0 8 8.0 99 99.0*

Note: *Total not 100% due to missing values

52

shoulder pain, wrist pain, carpal syndrome, amputation of foot, hip

pain, and foot pain. The respiratory category (4 records) included

pulmonary embolism, pneumonia, and COPD primary medical diagnoses. The

trauma category (12 records) was used only for the medical diagnosis,

status post motor vehicle accident. Urological diagnoses (3 records)

were prostate nodule, urinary bladder infection, and penile prosthesis.

Other diagnoses (7 records) were hemorrhoids, swallow partial palate,

arthritis, status post rhinoplasty, syncope, and status post middle ear

surgery. There was one record missing a medical diagnosis.

Defining Characteristics of Pain

Forty-four defining characteristics were found in the 100

records. Fifteen defining characteristics were from NANDA. Guarded

Behavior was the only category title used as a defining characteristic.

Twenty-one non-NANDA characteristics were from literature review. The

characteristics present in the records are listed in Table 5. Eight of

the non-NANDA characteristics were written in from the nurses' notes.

The eight additional characteristics were verbal expression of "hurts",

"sharp", "pain", "continuous", "intermittent", and "radiating".

Category 82, location words, was words that described location of the

pain. These were added under the verbal descriptor category. The last

addition was insomnia and placed under altered time perception

category. A total of 240 defining characteristics were present in 100

records.

53

Table 5. Defining Characteristics of Pain Present in Nurses Notes as Identified From Record Review

(N=100)

Number Number Characateristic Present Absent Total

C2 Aching 9 91 100 C6 Cramping 5 95 100 C7 Crushing 4 96 100 C13 Intolerable 1 99 100 C16 Nauseating 7 93 100

C17 Numbing 19 81 100 C19 Pounding 1 99 100 C21 Pulsing 1 99 100 C23 Sickening 1 99 100 C24 Shooting 5 95 100

C25 Stabbing 3 97 100 C26 Suffocating 1 99 100 C27 Tiring 1 99 100 C28 Tingling 12 88 100 C29 Throbbing 2 98 100

"C33 Verbalize Pain Medication 33 83 100 C35 Moaning 1 99 100 C38 Guarded Behavior 4 96 100 C39 Flexion Response 6 94 100 C40 Postural Readjustment 8 92 100

C42 > Heart Rate 1 99 100 C43 > Blood Pressure 1 99 100 C44 > Pulse 3 97 100 C45 > Respirations 1 99 100 C49 Body Repositioning 9 91 100

C50 Restless 3 97 100 C52 Sought Out Others 1 99 100 C54 Anxiety 5 95 100 C56 Muscle Tension 4 96 100 C57 Listless 4 96 100

(continued)

54

Table 5, continued

C59 Withdrawal 2 98 100 C60 Very Still 1 99 100 C67 Concentrating 2 98 100 C70 Facial Grimace 11 89 100 C72 Beaten Look 1 99 100 C75 Absence of Verbal Report 1 99 - " 100

C76 Hurts 5 95 100 C77 Sharp 10 90 100 C78 Pain 17 83 100 C79 Continuous 14 86 100

C80 Intermittent 3 97 100 C81 Radiating 2 98 100 C82 Location Words 7 93 100 C83 Insomnia 8 92 100

Total 240

Note: Dotted line across indicates end of original defining charac­teristics.

55

Total NANDA Characteristics

Table 6 presents the total NANDA characteristics by defining

characteristics. Fifteen defining characteristics were from the NANDA

list. Four records out of the 100 utilized guarded behavior as a

defining characteristic. Guarded Behavior, C38, was the only category

used as a defining characteristic. A total of 59 NANDA characteristics

was listed for 100 records.

Total Non-NANDA Characteristics

Twenty-nine non-NANDA characteristics were identified from 100

records. Twenty-four were under the verbal descriptors category. Seven

of the 24 were not from the original ACPAT tool. Anxiety was part of

the distraction behavior category. Concentrating was part of the self-

focusing category. Absence of verbal report was a part of the facial

mask of pain category. Altered time perception gained a new defining

characteristic, insomnia. Insomnia occurred in eight records or eight

percent of the records. Table 7 delineates the additional characteris­

tics by a line across the table. A total of 181 non-NANDA characteris­

tics were present in 100 records.

Categories of Defining Characteristics

The verbal descriptors category was present in 86 percent of

the records. A summary of the categories is listed in Table 8. The

other categories combined were found in less than one-fourth of the

records. Guarded behavior occurred in 16 percent of the records.

Table 6. The Total NANDA Characteristics by Defining Characteristic as Identified by Record Review

(N=100)

Present Categories Defining Characteristic Number Number

C38 Guarded Behavior 4 C39 Flexion Response . 6 18 GuardBe C40 Postural Readjustment 8

C42 > Heart Rate 1 C43 > Bood Pressure 1 6 ANS C44 > Pulse 3 C45 > Respirations 1

C49 Body Repositioning 9 C50 Restless 3 12 DistBe

C56 Muscle Tension 4 C57 Listless 4 8 AMT

C59 Withdrawal 2 C60 Very Still 1 3 NF

C69 Facial Grimace 11 C72 Beaten Look 1 12 FMP

Total Characteristics 59

Note: The defining characteristics which group together form the NANDA. NANDA characteristics are:

GuardBe Guarded Behavior ANS Autonomic Nervous System DistBe Distracted Behaviaor AMT Altered Muscle Tone NF Narrowed Focus FMP Facial Mask of pain

57

Table 7. Non-NANDA Defining Characateristics of Pain as Identified from Record Review

(N=100)

Characteristics Present Number

Category Number

C2 Aching 9 C6 Cramping 5 C13 Intolerble 4 C16 Nauseating 1 C17 Numbing 19 C19 Pounding 1 C21 Pulsing 1 C23 Sickening 1 C24 Shooting 5 C25 Stabbing 3 C26 Suffocating 1 C27 Tiring 1 C28 Tingling 12 C29 Throbbing 2 C33 Verbalize Pain Medication 33 C35 Moaning iq

C52 Sought Out Others 1 C54 Anxiety 5 C67 Concentrating 2 C75 Absence of Verbal Report 1

106 Verbal Descriptors

C76 Hurts 5 C77 Sharp 10 C78 Pain 17 C79 Continuous 14 C80 Intermittent 3 C81 Radiating 2 C82 Location Words 7 C83 Insomnia 8

Total Characteristics 181

58 Verbal Descriptors

Note: Dotted line across the table indicats end of original defining characteristics.

Table 8. Category of Defining Characteristics Number Per Record as Identified from Record Review

(N=100)

Number of Characteristics of Each Category Per Record

0 1 2 3 4 5 , Total

Categories # % # % # % #' % # % # % # %

Verbal Descriptor

14 14.0 41 41.0 26 26.0 13 13.0 5 5.0 1 1.0 100 100.0

Guarded Behavior

84 84.0 15 15.0 - 1 1.0 - - - 100 100.0

Distraction Behavior

84 84.0 14 14.0 2 2.0 - - - - - 100 100.0

Facial Mask of Pain

88 88.0 11 11.0 1 1.0 - - - - - 100 100.0

Altered Time Perception

92 92.0 8 8.0 - - - - - - - 100 100.0

Alteration in Muscle Tone

93 93.0 6 6.0 1 1.0 - - - - - 100 100.0

Autonomic Response

96 96.0 3 3.0 - - 1 1.0 - - - 100 100.0

Narrowed Focus

97 97.0 3 3.0 - - - - - - - 100 100.0

Self-Focusing 98 98.0 2 2.0 - - - - - - - 100 100.0

59

Distraction behavior was present in 16 percent of the records. Facial

mask of pain category occurred in 12 percent of the records.

Results Related to the Research Questions

The two research questions were: 1) Which signs and symptoms of

the Alteration in Comfort-Pain composed the critical cluster of

defining characteristics for the nursing diagnosis? 2) Given a client

presenting the signs and symptoms of Alteration in Comfort-pain, what

did the nurses identify for the presence of the nursing diagnosis

Alteration in Comfort-Pain?

The final critical cluster of signs and symptoms of Alteration

in Comfort-Pain composed both the general defining characteristics from

the original ACPAT and the actual defining characteristics found in the

study. Verbal descriptors was the only category present in over 60

percent of the records. Verbalization of pain medication was the

patient's request for pain medication as documented by the nurse.

Verbalization of pain medication was the only defining characteristic

comprising at least 10 percent of the total defining characteristics.

No one defining characteristic was present in 100 percent of the

records. Therefore, one critical defining characteristic was not found.

The three distinct categories utilized from NANDA were guarded

behavior, distraction behavior, and facial mask of pain. Guarded

behavior, distraction behavior, and facial mask of pain were each found

in over 10 percent of the records. Verbal descriptors largely made up

the non-NANDA defining characteristics, 86 percent of the records. Many

of the verbal descriptors were from literature review and new ones from

60

nursing notes. The final defining characteristic category was present

in 10 percent or more of the records. As a result, the defining

characteristics of each prominent category were considered part of the

final critical cluster. Table 9 ranks the final critical cluster of

signs and symptoms by category and individual defining characteristic

from highest frequency to lowest frequency.

As indicated in Table 9, nurses primarily identified a

patients' pain through his verbalization. And nurses recognized pain as

a problem when it required her assistance, for example obtaining pain

medications. However, nurses did recognize other verbal indicators

like "numbing", "painful/in pain", "continuous", "tingling", and

"sharp". Eighty-six records indicated the patient verbalizing pain.

Nurses also used non-NANDA characteristics more frequently than

NANDA characteristics. Table 10 lists the number of characteristics per

record. Sixty-four of the records did not use one NANDA defining

characteristic. Twenty-two had one characteristic. Fourteen percent of

the records had two to five characteristics per record. Table 11

illustrates that all of the records had at least one non-NANDA

characteristic. Fifty-seven records had one characteristic. Twenty-four

percent had two or more characteristics. Nineteen percent of the

records had three or more characteristics which were non-NANDA

characteristics.

Summary

The demographic data indicated the majority of the sample was

60 to 69 years of age, Caucasian, and married. Approximately one-third

61

Table 9. Final Critical Cluster of Signs and Symptoms Present in Ten Percent or More of the Records

(N=240 Characteristics)

Characteristics/ Records Characteristics Categories # % # %

Verbal Descriptors 86 86.0

Verbalize Pain Medication 33 13.8 Numbing 19 7.9 Pain 17 7.0 Continuous 14 5.8 Tingling 12 5.0 Sharp 10 4.1

Guarded Behavior 16 16.0

*(Guarded Be.) 4 1.6 *Flexion Response 6 2.5 *Postural Readjustment 8 3.3

Distraction Behavior 16 16.0

*Body Repositioning 9 3.8 *Restless 3 1.3 Anxiety 5 2.1

Facial Mask of Pain 12 12.0

Facial Grimace 11 4.6

* Items indicate NANDA characteristics

62

Table 10. Total NANDA Characteristics by Number Per Record as Identified from Record Review

(N=59)

Number of Characteristics Per Record

Records 0 1 2 3 4 5

Number 64 22 9 2 2 1

Percent 64.0 22.0 9.0 2.0 2.0 1.0

Total

59

100.0

63

Table 11. Total Non-NANDA Defining Characteristics by Number Per Record as Identified from Record Review

(N=181)

Number of Characteristics Per Record

Records 1 2 3 4 5 6 7 8 Total

Number 57 24 11 3 2 1 1 1 181

Percent 57.0 24.0 11.0 3.0 2.0 1.0 1.0 1.0 100.0

64

of the patients had orthopedic medical diagnoses, and about one-half of

the patient diagnoses were surgically related. Verbalization of pain

medication or the patient's request for pain medication and the verbal

descriptor category comprised the critical cluster of the defining

characteristics for Alteration in Comfort-Pain. Secondly, non-NANDA

characteristics were recorded by nurses more frequently and seemed to

be more recognized more frequently in the clinical setting. The

discussion and implications of these results and recommendations for

further research studies follow in the next chapter.

CHAPTER 5

DISCUSSIONS, IMPLICATIONS AND RECOMMENDATIONS

Presentation of the results of data analysis was given in

Chapter Four. Nurses primarily identified patient's pain through the

patient's verbalizations.

A discussion of the results related to the sample, instrument

and research questions is presented in Chapter Five. Also, sources of

potential error, recommendations for further study, and implications

for nursing are presented.

The Sample and Instrument

The homogeneity in gender and ethnicity of the sample limits

the generalization of the results. One-third of the sample had ortho­

pedic diagnoses and more than one-half involved surgical diagnoses. The

large number of orthopedic and surgical diagnoses might have biased the

results of the defining characteristics. For instance, "tingling" and

"numbing" verbal descriptors were very frequent and would be associated

with orthopedic diagnoses. However, with the criterion set for defining

characteristics to occur in 60 percent of the records, the bias for

specific categories was minimized.

The content validity of the ACPAT yielded 100 percent agreement

for all the characteristics. In fact, the instrument's content validity

65

66

is a strength of the study. When noting other defining characteristics

of pain, only eight additional characteristics were added from 100

records.

Discussion Related to Research Questions

Question #1

Which signs and symptoms of Alteration in Comfort-Pain composed

the critical cluster of defining characteristics for the nursing

diagnosis?

The final defining characteristic: critical cluster was the

comparison and synthesis of the General Defining Characteristics and

Actual Defining Characteristics. The criterion set in this study for a

defining characteristic to be part of the critical cluster was that the

defining characteristic must be present in at least 60 percent of the

records. A critical defining characteristic must be present in every

record to formulate the nursing diagnosis of pain. Only one category of

defining characteristics, the verbal descriptors, was present in 60

percent or more of the records. No defining characteristic was present

in the records 100 percent or 60 percent of the time. Verbalization of

pain medication, a defining characteristic, was present in 30 percent

or more of the records. As a result this investigator focused on cate­

gories present in the records and the frequent characteristics in each

category. The verbal descriptor category was present in 86 percent of

the nurses' notes. One hundred sixty-four verbal defining characteris­

tics were present out of 240 defining characteristics. The defining

67

characteristics, verbalize pain medication, "pain", "continuous", and

"sharp" were actual non-NANDA defining characteristics present.

"Numbing and tingling" were the non-NANDA defining characteristics

present from literature review.

Guarded Behavior was the next critical cluster category and

defining characteristic used. Guarded Behavior was the only category

used as a defining characteristic. Flexion response and postural

readjustment were defining characteristics from NANDA. Distraction

Behavior composed of body repositioning and restless were from NANDA

listings and the most frequent in actual defining characteristics.

Anxiety, a non-NANDA defining characteristic may have been significant

due to the number of surgical patients in the sample. Finally, facial

grimace was as frequently occurring as the verbal descriptors. The

total non-NANDA characteristics were 29 compared to the 15 total NANDA

characteristics. Verbal, guarded behavior, distraction behavior, and

facial mask of pain defining characteristics categories comprise the

final defining characteristics of the critical cluster.

Because pain is subjective and highly individualized, one

defining characteristic would not emerge with a criterion set at 60

percent. The investigator agrees with Melzack, that pain defies defini­

tion. However, studies of the verbal descriptors and nursing interven­

tions must be conducted to increase nurses' understanding of pain and

how to intervene. A greater total of non-NANDA characteristics versus

NANDA characteristics indicated that the present categories of defining

characteristics are inadequate and possibly not representative of pain

68

in the clinical setting. Furthermore, the non-NANDA characteristics

were largely composed of the verbal descriptors of the defining charac­

teristics. The cluster of characteristics forming the verbal descriptor

did occur for 86 of the patients. One hundred sixty-four verbal defin­

ing characteristics were present out of the 240 defining characteris­

tics. In future studies, the verbal descriptors need to be developed

according to the meaning of different word groups and their possible

nursing interventions. An example, "tingling and numbness", "guarded

behavior", and "postural readjustment" occurred in 80 percent of the

patients with orthopedic diagnoses, suggesting a neurological involve­

ment.

Verbal descriptors need to be developed in chronic pain versus

acute pain. A majority of the sample was surgical patients who would be

expected to have more acute pain. Anxiety was listed as a pain charac­

teristic in ten of the records. Nursing interventions are very

different for chronic versus acute pain and interventions are not well

developed for either type. A study of characteristics of chronic and

acute pain would also develop the definition of pain and nursing inter­

ventions for each type.

Another verbal category developed from this study was quality

descriptors of pain such as "sharp" and "continuous". Quality descrip­

tors aided the nurse to locate the etiology of pain or how to treat the

patient's pain.

The defining characteristics, patient's report for pain medica­

tion and why it was present for 33 patients will now be discussed.

69

Because the defining characteristics for pain are not developed, this

study indicated that nurses recognize and document patient's pain

through their primary intervention for pain, pain medication. For

example, in responding to a patient's request for pain medication, the

nurse will focus on the request and response rather than specific des­

criptors on the patient's pain. If nurses' notes had verbal descriptors

in categories with accompanying interventions other than pain medica­

tions, nurses might document more specific verbal, behavioral, and

locating descriptors, which leads us to the second study question.

Question #2

Given a client presenting the signs and symptoms of Alteration

in Comfort-Pain, what did nurses identify as the defining characteris­

tics of the nursing diagnosis Alteration in Comfort-Pain?

Nurses identified the defining characteristic of Alteration in

Comfort-Pain as verbalization of pain medication and utilized the

verbal descriptor category 86 percent of the time. The underlying

assumption on the nurse's part is: pain is what the patient states it

is. Secondly, non-NANDA characteristics were recorded by nurses more

frequently and seemed to be recognized more frequently in the clinical

setting. All of the records had at least one non-NANDA defining

characteristic. Sixty-four percent of the records did not have one

NANDA characteristic. These results could have one of two meanings.

One, the NANDA defining characteristics are not applicable in the

clinical setting. Secondly, nurses do recognize them as valid defining

70

characteristics, but nurses are not documenting them. Omission of

documenting these characteristics may be due to the format of the

nursing note; some pain characteristics do not require nursing

intervention or time to document; or nurses lack knowledge of the

defining characteristics of pain.

Source of Potential Error

The three sources of potential error were the investigator's

bias, the sampling procedures, and the exclusion of the negations of

the defining characteristics. Since the investigator conducted the data

collection, one must consider that bias might occur especially when

emotional meaning develops with time. How much bias has occurred is

unknown.

Because the computer printout used to obtain the sample

included only medical diagnosis with the word "pain", omission of

nursing notes with the diagnosis of Alteration in Comfort-Pain may have

occurred. Examples of nurses' notes omitted might be involved with

documentation of characteristics of chronic pain or characteristics of

pain in patients with chronic illness. The fact that most of the

patients had acute pain associated with surgery may have biased the

type of defining characteristics of pain to acute rather than

chronic.

Finally this investigator noted many notes with negations of

defining characteristics of pain, especially as the patient recovered.

71

Some of the negations were "No report of pain" or "able to move more

freely". These negations were not included in the present study.

Recommendations for Further Study

The following recommendations for further study are offered:

1. Further study is needed to identify the effect of type of

nursing note format on documentation and standardization of

defining characteristics of nursing diagnosis.

2. Research is needed to extend the NANDA list by developing the

verbalization category and defining characteristics.

3. Research is needed to identify and compare acute pain and

chronic pain's defining characteristics.

4. Further research is needed to compare the patient's perception

of pain and the nurses' documentation of that pain.

5. Research is needed to identify nurses' knowledge regarding

defining characteristics for pain.

6. Research is needed to identify the reasons for the lack of

nursing documentation using NANDA characteristics.

7. Further research is needed to compare defining characteristics

of pain to outcome behaviors of patients in pain.

8. Research which considers a heterogeneity of the sample in both

gender and ethnicity is needed.

Implications for Nursing

Implications of the present study for nursing are significant

and clinically relevant. As descriptors of pain are developed, nursing

72

interventions toward pain will become sensitive and specific to each

patient. The variety of interventions for each verbal descriptor

category will increase from giving pain medications to include

interventions such as providing a back rub, using imagery with chronic

pain, and suggestive hypnosis. Nurses will also be held accountable for

diagnosing the appropriate acute pain nursing diagnosis with the

appropriate treatment designated by standards at the time. Furthermore,

development of chronic pain to specific chronic pain diagnoses and

treatment for each chronic pain diagnosis will also increase autonomy

and accountability in the same manner as for acute pain.

A computer program can be used to store all the classifications

with their etiologies and interventions. Then the nurses could have

easy access to not only nursing diagnosis for pain but all nursing

diagnoses. Furthermore, a potential exists for a pain nurse specialist

to evolve as a nursing role.

Another implication concerns the ongoing quality assurance

programs. Since the presence of a quality assurance program influenced

the consistency and quality of nurses' notes, nurses need to develop

and maintain the ongoing process. Nurses need ongoing education in the

development of defining characteristics of nursing diagnosis as

research expands the field. Nurses also need to evaluate their formats

of documentation. Some preprinted admission nursing note formats as

described in the study do not allow places for assessment or nursing

interventions. Therefore, does the format allow space for nurses to

document their interventions and diagnoses? Including a list of

73

defining characteristics for each nursing diagnosis frequently used in

a given area of work would ensure consistent and complete documentation

of a nursing diagnosis as noted in the preprinted admission nursing

note formats. Does the nursing unit include an easily accessible

reference or list of defining characteristics for the frequently used

nursing diagnosis in the specific area of nursing?

Finally, nurses need to be careful and aware of their

perceptions and goals for patients, when formulating their diagnosis

and interventions. This is indicated from the results of the second

study question on what nurses documented as defining characteristics of

Alternation in Comfort-Pain. Rankin (1984, p. 154) in her report of

pain perception in 52 cancer patients concluded "the goal for narcotic

administration for 58% of the nurses was to reduce pain rather than

relieve it". Although addiction appeared not to be a conscious factor

in the nurse's assessment process, the data seems to indicate that they

often perceived moderate relief of pain as an appropriate goal.

Taylor's research (1984, p. 7) indicated "more negative personality and

behavioral traits were attributed to the patient when signs of

pathology were negative". Taylor's research focused on 268 cancer

patients and chronic pain. Her research indicated that nurses believed

pain reducing measures were less effective or appropriate with patients

considered a psychological problem versus a physiological problem. So a

depressed patient may be perceived as a malingerer, while in actuality

the pain may be a source of depression. Thus, nurses documented

defining characteristics according to their perceptions of what is

74

pertinent, and what is pertinent may be wrong if their perceptions are

incorrect.

Summary

Chapter Five presented a discussion of the results of the

research questions, the sample and instruments, sources for potential

error, recommendations for further research, and implications for

nursing.

This study provided the foundation for further types of group

comparisons, environmental considerations, and controls to decrease

bias in research of defining characteristics of nursing diagnoses. The

development and validation of the ACPAT tool is provided for future

studies of the nursing diagnosis, Alteration in Comfort-Pain. Finally,

this study described and extended the NANDA listings of defining

characteristics for the nursing diagnosis, Alteration in Comfort-Pain.

APPENDIX A

UNIVERSITY OF ARIZONA COLLEGE OF NURSING HUMAN SUBJECTS APPROVAL

75

76

T H E U N I V E R S I T Y O F A R I Z O N A T U C S O N , A R I Z O N A 8 5 7 2 1

C O L L E G E O F N U R S I N G

MEMORANDUM

TO: Irene D. Tidwell, BSN Graduate Student College of Nursing

FROM: Ada Sue Hinshaw, PhD, RN Director of Research

Merle Mi she!, PhD, RN Chairman, Research Committee

DATE: March 10, 1986

RE: Human Subjects Review: Nursing Diagnosis: Alteration in Comfort-Pain: Validation of the Defining Characteristics

Your project has been reviewed and approved as exempt from University review by the College of Nursing Ethical Review Subcommittee of the Research Committee and the Director of Research. A consent form with subject signature is not required for projects exempt from full Uni­versity review. Please use only a disclaimer format for subjects to read before giving their oral consent to the research. The Human Subjects Project Approval Form is filed in the office of the Director of Research if you need access to it.

We wish you a valuable and stimulating experience with your research.

ASH/fp

APPENDIX B

VETERANS' ADMINISTRATION RESEARCH AND DEVELOPMENT COMMITTEE APPROVAL

77

Veterans \>w Administration Memorandum

Datt: March 27, 1986

From Chairman, R&D Committee

Suoi: #015 - Nursing Diagnosis: Alteration in Comfort-Pain: Validation of the Defining Characteristics

To: Robin Palmer, R.N., & Irene Tidwell, R.N.

1. The above referenced protocol vas reviewed by the Research and Development Committee at its meeting of March 26, 1986 and approved.

2. An initial report is due vithin 15 days of the commencement of the study, and a progress report Is due yearly on the anniversary date. A final report is due when the study is ended for any reason. For your convenience, a form 10-1A36 is attached.

Chief, Renal Section

Attachment

APPENDIX C

NURSING PREPRINTED ADMISSION NOTE STANDARD FORM 507

79

ptMD.&AT& Form SOT

CLINICAL RECORD Report on JlUR8INq HISTORY AND ASSESSMENT

or Continuation ol S. F. MED1CAL-8URQICAL

oul en* fir* t) (Spicily typ* ot niminitipn or data)

DATE Of HISTORY TIME OF HISTORY

A OMITTING MEDICAL DIAGNOSIS

REASONS FOR HOSPITALIZATION VALUABLES - YES _ NO PTCKED UP BY MAS - YES -NO PATIFNT AP.RFPTFT NFWWJCINN ITV tnn

TAKFMHOUC RV

RELATIONSHIP HOW HAS THE PATIENT BEEN MANAGING THE ABOVE PROBLEMS AT HOME*

CLOTHING-YES-NO SENT TO CLOTHING ROOM—YES —NO TAKFN HFTTJF OV

RELATIONSHIP OTHER ILLNESSES OR CONDITIONS (HYPERTENSION. ARTHRITIS. DIABETES. PAST SURGERIES. ETC 1

ALLERGIES (FOOO. MEDICATION. TAPE. ETC)

USE OF ALCOHOL OR TOBACCO (AMOUNT) LAST ftffSlCAL EXAM TYPE Of REACTION

• MEOICATION AND DOSAGE PRESCRIBED AND NON-PRESCRISEO MTIENrS UNDERSTANDING OF PURPOSE

SUBJECTIVE DATA

LIMITS OR RESTRICTIONS RELATED TO VISION - YES .

HEARING - YES - NO OTHER _ YES - NO

DESCRIBE

LAST EYE EXAM

REPORT OF DYSPNEA. COUGH. ORTHOPNEA, FTC

OBJECTIVE DATA

CONTACT LENSES ——

ARTIFICAL EYE

HEARING AIQ

BREATH SOUNOS. SPUTUM. ETC

REPORT Of CHEST PAIN. NUMBNESS. TINGLING. ETC PERIPHERAL PULSES. CAPILLARY REFILL. EDEMA. ETC

TEMP .

BP

O-AX-R PULSES_AP_R QUALITY

R _L .LYING _ SITTING _ 5TAN0ING

'FAfiCNT'l ICLNI li».CAT;ON (For typ*d ot wtittinarttnvt /»»• A'i middle, ftada; data, hotpmlor madicaHaciltty)

REGISTER NO.

REPORT OH. or CONTINUATION OF

STANDARD FORM 507 Cwril StfYicn A4ml«lstr»ti«n ml

lRliti|nty Comm.riM en Mtdicil R«c*fri« rPUK 101-11.M *-« Octet* 1979 S07-1M

5E*S*W<»I tm

81

IUSJIC71VI0AT* OMCTIWOKIft V<

1 M a 3

REPORTED PRUAITIS. ECZEMA. PSORIASIS. ETC. INSPECTION FOR RASHES. OPEN AREAS ANO ABNORMAL NAIL CONOITION. ETC. NOTE DISTRIBUTION ANO OUALITV OF HAIR OR PRESENCE 0^ VflQ

w K z

LAST SELF BREAST EXAM

..Cyanotic

.Pw

.rtmhad _CH»phOffWC

_W*m

.Hoi

-Or*

-Cow

-Turgor

INOICATE ON DIAGRAM All BODY MARKS SCARS.

BRUISES. OISCOLORATION LACERATIONS. OECUBITI.

QUESTIONABLE MARKINGS

;J>

oi

IS

REPORTS OF ANOREXIA NAUSEA. MEAL PATTERN. ABILITY TO CHEW A SWAUOW. RECENT CHANGE IN WEIGHT.

SKIN TURGOR. APPEARANCE OF TONGUE. TEETH. ETC

52 XX

THERAPEUTIC DIET LAST OENTAl EXAM HEIGHT WEIGHT OENTURES

z o

5

BOWEL HABITS. VOIDING PATTERN. HEMORRHOIDS. DESCRIPTION OF MENSTRUAL CYCLE. ETC

DIAPHORESIS BOWEL SOUNDS. APPEARANCE OF URINE. FECES, VOMITUS. ETC.

f REPORTED LAST BM LAST PAP SMEAR LAST PROCTO EXAM

S o

REPORTED INABILITY TO DO AOLS. DIFFICULTY WITH AMBULATION. TRANSFER. ETC

ROM. GAIT. STRENGTH. ENDURANCE. ETC

WA« KPO oariCTueeie

^ t-«2 OK

REPORT OF PAIN QUALITY LOCATION. PRECIPITATING FACTORS. DURATION AND HOW PAIN IS RELIEVED

FACIAL GRIMACING. GUAROING OF AFFECTED AREA. ETC (NOTE THERE MAY 8E NO OBSERVABLE SIGNS WITH CHRONIC PAIN)

REPORTED SLEEP PATTERNS ANO BEDTIME RITUALS

. < 3 o M o z o >

s

OESCRIBE MEMBERS OF SUPPORT SYSTEM OR IMMEOIATE HOUSEHOlO (AGE. HEALTH STATUS. ETC) PATIENT S RESPONSE TO CHANGE OR STRESS

OBSERVEO NON-VERBAL BEHAVIOR. INTERACTIONS WITH SIGNIFICANT OTHERS. ETC

OCCUPATION AND/OR INTERESTS

ANTICIPATED DESTINATION AT OISCHARGE/OESCRIPTION OF ENVIRONMENT

UTILIZATION OF COMMUNITY RESOURCES'PERCEPTION OF NEED

_CHN _H8HC — SOCIAL SERVICE OTHER

TYPE OF SERVICE PROVIDED'NEEDEO

_CHN _HBHC—SOCIAL SERVICE _Cl SPECIALIST

OTHER

SIGNATURE

APPENDIX D

NURSING PREPRINTED ADMISSION NOTE STANDARD FORM 509

82

MEDICAL RECORD PROGRESS NOTES

TIME & SUBJECTIVE: DATS

NURSING ADMISSTOW T n itmtt

Physical Problems (Problems""for which admitted):

F . m n t i n n a l S l - a t i i « -

j

Admitted by: W/C Stretcher Amb. Other

«"«°"i»«r Defuies-^s^TTo; ; Eyeglasses, Yes No Valuables (money, jewelry) Yes No

K —'yes'-'-to valuables,- deaurlbe

Physical Signs and Symptoms:

Mental Status and Emotional Behavior:

1/ cOfffuSed aria/or disoriented and patient has valuables, MAS notified: Yes No .

Approved by M/R Sub-Com 8/11/78 OP 136C-78-2

(Continue on rtttne tide)

PATENT'S KXNTIftCATION Iff 1*4 - wnutm t gmtr. tmk «MT.

n pw VMW>IW. fim mid4b w fanhrt!

REGISTER NO

PROGRESS NOTES STANOARO *ORU sot tt-TT)

•» CSA/f>* (MM i4i ai) IOM.WM

5C«-110

IMIl ASSESSMENT:

PROGRESS NOTES

ILAH: Nterelng Care-Initiated «o-AdBte*imi

(Juala7~

Patient and/ot Fftally Education!

Hurslng Signature:,

• U.S. CNVL.RNMCNT PNIW INC 'HI LL'L 1"«L HI - 1 I IH ' .L SrANOAAO fOMI sot BACH U-77)

APPENDIX E

ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL

85

86

ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL9.

Record Number

Patient age Nursinq unit (SMI) Marital status SMWD Ethnic oriqin CBAIH Medical diagnoses

DEFINING CHARACTERISTICS TOTALS

VERBAL CHARACTERISTICS

CI* (Verbal descriptors)

C2 Poundinq C3 Pulsinq C4 Throbbinq C5 Shootinq C6 Dartinq C7 Piercinq C8 Stabbinq C9 Cuttinq CIO Crampinq Cll Crushinq C12 Pullinq C13 Wrenchinq C14 Scaldinq C15 Tinqlinq C16 Achinq C17 Numbinq C18 Tirinq C19 Fatiquinq C20 Sickeninq C21 Nauseatinq C22 Suffocatinq C23 Friqhtful C24 Gruelinq C25 Killinq

TOTALS

a Tidwell, I.D., 1986 * Defining Characteristics approved by NANDA

87

DEFINING CHARACTERISTICS Record Number

TOTALS C26 Agonizing C27 Annoying C28 Intolerable C29 Horrible C30 Miserable C31 Troublesome C32 Unbearable C33 Verbalize pain

medication C34 Sighing C35 Moaning C36 Screaming C37 Crying

GUARDED BEHAVIOR

C38* (Guarded Behavior) C39* Flexion response C40* Postural readjust

AUTONOMIC RESPONSE

C41* (Autonomic response) C42* > heart rate C43* > BP C44* > pulse C45* > respirations C46* > pupils

DISTRACTION BEHAVIOR

C47* (Distraction Behavior)

C48* Pacing C49* Body repositioning C50* Restless C51 Smoke increase C52 Sought out others C53 Talkinq constantly C54 Anxiety

TOTALS

* Defining Characteristics approved by NANDA

88

DEFINING CHARACTERISTICS Record Number

TOTAL

ALTERATION IN MUSCLE TONE

C55* (Alteration in muscle tone)

C56* Muscle tension C57* Listless

NARROWED FOCUS

C58* (Narrowed focus) C59* Withdrawal C60* Very still

ALTERED TIME PERCEPTION

C61* (Altered time perception)

C62* Impaired thoughts C63 Sleeps

SELF FOCUSING

C64* (Self-focusinq) C65 Countinq C66 Deep visualization/

imaqerv C67 Prayer C68 Concentrating C69 Day-dreaming

TOTALS

89

DEFINING CHARACTERISTICS Record Number

TOTAL

FACIAL MASK OF PAIN

C70* Facial mask of pain

C71* Facial grimace C72* Eyes lack luster C73* Beaten look C74 Dilated pupils C75 Depressed C76 Absence of verbal

report

TOTALS

LEGEND

Nursing Units S=surgical M=medical I=intensive Marital Status S=single M=married W=widowed D=divorced Ethic origin C=Caucasian B=Black I=American Indian

H=Hispanic

*Defining characteristics approved by NANDA

(Self-focusing) parenthesis designates a category

APPENDIX F

REVISED ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL

90

91

ALTERATION IN COMFORT-PAIN ASSESSMENT TOOL3

Record Number

Patient aqe Nursinq unit (SMI) Marital status SMWD Ethnic oriqin CBAIH Medical diagnoses

DEFINING CHARACTERISTICS TOTALS

VERBAL CHARACTERISTICS

CI* (Verbal descriptors)

C2 Aching C3 Agonizing C4 Annoying C5 Cutting C6 Cramping C7 Crushing C8 Darting C9 Fatiguing CIO Frightful Cll Grueling C12 Horrible C13 Intolerable C14 Killing C15 Miserable C16 Nauseating C17 Numbing C18 Piercing C19 Pounding C20 Pulling C21 Pulsinq » C22 Scalinq C23 Sickening C24 Shooting C25 Stabbing

TOTALS

a Tidwell, I.D., 1986 * Defining Characteristics approved by NANDA

92

DEFINING CHARACTERISTICS Record Number

C26 Suffocating" TOTAL

C27 Tiring C28 Tingling C29 Throbbing C30 Troublesome C31 Unbearable C32 Wrenching C33 Verbalize pain

medication C34 Sighing C35 Moaning C36 Screaming C37 Crying

GUARDED BEHAVIOR

C38* (Guarded Behavior) C39* Flexion response C40* Postural readjust

AUTONOMIC RESPONSE

C41* (Autonomic response) C42* > heart rate C43* > BP C44* > pulse C45* > respirations C46* > pupils

DISTRACTION BEHAVIOR

C47* (Distraction Behavior)

C48* Pacing C49* Body repositioning C50* Restless C51 Smoke increase C52 Sought out others C53 Talking constantly C54 Anxiety

TOTALS

* Defining Characteristics approved by NANDA

93

DEFINING CHARACTERISTICS Record Number

TOTAL ALTERATION IN MUSCLE TONE

C55* (Alteration in muscle tone)

C56* Muscle tension C57* Listlessness

NARROWED FOCUS

C58* (Narrowed focus) C59* Withdrawal C60* Very still

ALTERED TIME PERCEPTION

C61* (Altered time perception)

C62* Impaired thoughts C63 Sleeps

SELF FOCUSING

C64* (Self-focusinq) C65 Countinq C66 Deep visualization/

imaqery C67 Concentrating C68 Day-dreaming

TOTALS

94

DEFINING CHARACTERISTICS Record Number

TOTAL FACIAL MASK OF PAIN

C69* Facial mask of pain

C70* Facial grimace C71* Eyes lack luster C72* Beaten look C73 Dilated pupils C74 Depressed C75 Absence of verbal

report

TOTALS

LEGEND

Nursing Units S=surgical M=medical Marital Status S=single M=married w=widowed Ethic origin C=Caucasian B=Black

H=Hispanic

•Defining characteristics approved by NANDA

(Self-focusing) parenthesis designates a category

I=intensive D=divorced I=American Indian

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