Comforting the Neonate; Application of the Comfort Care Theory

Comforting the Neonate; application of the Comfort Care Theory

Introduction

An anonymous author once said, "In the last stages of a final illness, we need only the absence of pain and the presence of family." The comfort care theory by Katharine Kolcaba exemplifies this by creating a baseline of quality care that both nurses and doctors can utilize in providing care to a dying patient. Comfort has been called a distinguishing characteristic of the nursing profession yet, until Katharine Kolcaba, had never been conceptualized within a theory for nursing (Kolcaba, 1994). In pediatrics, written protocols for end of life care are more directed at pain relief than providing comfort to the patient. In the area of pediatrics, care is not only provided to the patient, comfort is also provided to the family as they deal with unexpected trauma, congenital malformations, and terminal diagnoses (Kolcaba and DiMarco, 2005). Kolcaba defines comfort as the immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, social, and environmental)(Kolcaba, Tilton, and Drouin, 2006). Some of these strategies can be as simple as facilitating a child's special "self-comfort habits," such as thumb-sucking, blanket holding, or rocking, and advocating presence of family members (Kolcaba and DiMarco, 2005).

Overview of Selected Theory

Katharine Kolcaba began development of the comfort theory as a graduate student in 1988. The comfort theory was officially published in 1994 and has been modified since publication (McEwen and Willis, 2007). The theory of comfort care is a middle mid-range theory which is easily applied to practical settings by clinicians. In addition, it classifies as a middle mid-range theory due to its recognized ability to be generalized. It also generates testable hypotheses, but is less comprehensive than a grand theory (Fawcett, 2005). The concept of comfort care was developed into a patient/family-centered theory. Kolcaba recognized three types of comfort: relief, ease, and transcendence. Moreover, human experience takes place in 4 contexts: physical, psychospiritual, social, and environmental. The basis of Kolcaba's theory is a taxonomic structure or grid that has 12 cells (Kolcaba, 1992). The three types of comfort are listed at the top of the grid and the four contexts in which comfort occurs are listed down the side of the grid. Kolcaba's purpose in development of the theory was increasing comfort, which can result in negative tensions reduced and positive tensions engaged. Kolcaba defined the concepts of nursing's metaparadigm in the areas of: person, health, environment, and nursing. Kolcaba describes person as all individuals. All individuals can be defined as care recipients, individuals, families, institutions, or communities in need of health care. Health is defined as optimal functioning by the patient, family, or community. Functioning is not mentioned specifically in her theoretical definitions; however, perception of comfort is discussed multiple times. Environment is a major factor in implementing the comfort theory. The environment is any aspect of the patient, family, or institution that can be manipulated to aide and improve the patient's comfort level perception. Nursing is the intentional assessment of comfort needs, design of comfort measures, and implementation and evaluation of comfort measures as in a care plan. This is done by asking questions or observing.

Case Scenario

The case study of interest is about a baby that will be referred to as Caitlin. Caitlin was a twenty-three week baby born to a primigravida forty-year-old mother. Caitlin was born via caesarean section, intubated immediately and brought to the Neonatal Intensive Care Unit. Caitlin was only given a 10 percent chance of survival at birth due to her extremely low gestational age and birth weight. Upon admission, porcine surfactant (Survanta) was given, along with placement of multiple umbilical lines. Caitlin was also placed in a humidified isolette which was covered with a dark blanket to create as much of a pseudo uterine environment as possible. Within twenty-four hours of life, Caitlin was already over the "honeymoon" phase experienced by most preterm babies. Caitlin's sodium level had climbed to an amazing 180 mg/dL and her glucose was over 400 mg/dL. All of Caitlin's intravenous fluid therapy had to be changed to minimal glucose and without sodium. She was also started on an insulin drip to aid in reduction of her glucose. Just as Caitlin's glucose was becoming controlled, her potassium began to climb and reached an extreme of 8.3 mg/dL. This began a series of over 22 glucose and insulin boluses. Aside from the hemodynamic rollercoaster Caitlin was on, her respiratory status was less than optimal. Progression of worsening respiratory compliance and poor kidney function from her extreme prematurity caused Caitlin to be in a state of continued acidosis. She was started on a low dose sodium bicarbonate drip, which complicated her already high sodium and exacerbated her chronic carbon dioxide retention. The bicarbonate drip was discontinued due to the side effects, and the metabolic acidosis from poor kidney function and respiratory acidosis from decreased lung compliance became just "where Caitlin lived."

On day fourteen of life, another huge setback happened to Caitlin. Upon receiving an ultrasound of her head, she was discovered to have a grade IV intraventricular hemorrhage (the worst possible scenario), compounding the already growing list of problems for the tiny person. Another problem of Caitlin's chronically poor respiratory status was the silent damage the high levels of oxygen were doing to her retinas. Over time, an increased oxygen level exposure can detach the retinas of tiny babies, a condition known as retinopathy of prematurity. At six weeks of life, Caitlin was deemed totally blind with no chance of rejuvenation.

Finally, on Caitlin's three-month birthday, she was extubated to continuous positive airway pressure (CPAP) and allowed to suck. During Caitlin's four weeks on CPAP, she was beginning to look and act like a real baby. She was dressed in the cutest clothes and had a pacifier for every outfit she wore. She was given lemon-glycerin swabs to suck, as she was just not quite strong enough to swallow milk. After a month on CPAP, Caitlin moved to a high flow nasal cannula and given her first bottle. Nothing kept the little baby happier than the ability to suck and swallow her own bottle without having an endotracheal tube or feeding tube impeding