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Rationale for Comfort Interventions

The nursing diagnosis is impaired comfort related to symptoms of hyperbilirubinemia including weakness, decreased appetite, poor sucking, and lethargy. Hyperbilirubinemia is caused by excessive red blood cell destruction exceeding the liver's ability to conjugate bilirubin, raising unconjugated bilirubin levels. The nursing goal is for the patient to engage in behavior changes to increase their level of comfort after interventions. Interventions include determining the type and cause of discomfort, establishing the context of discomfort, validating support systems, reviewing coping skills and medications, suggesting parental presence, providing age-appropriate comfort measures, and encouraging rest.

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Brix Valdriz
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178 views3 pages

Rationale for Comfort Interventions

The nursing diagnosis is impaired comfort related to symptoms of hyperbilirubinemia including weakness, decreased appetite, poor sucking, and lethargy. Hyperbilirubinemia is caused by excessive red blood cell destruction exceeding the liver's ability to conjugate bilirubin, raising unconjugated bilirubin levels. The nursing goal is for the patient to engage in behavior changes to increase their level of comfort after interventions. Interventions include determining the type and cause of discomfort, establishing the context of discomfort, validating support systems, reviewing coping skills and medications, suggesting parental presence, providing age-appropriate comfort measures, and encouraging rest.

Uploaded by

Brix Valdriz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING DIAGNOSIS: Impaired Comfort related to Illness-Related Symptoms of

Bilirubinemia as manifested by Body weakness, Decreased Appetite, Poor Sucking and


Lethargy
NURSING INFERENCE: Impaired comfort is caused by the signs and symptoms of
hyperbilirubinemia due to hematologic mechanisms. Excessive hemolysis (destruction)
of red blood cells can cause hemolytic jaundice which in turn increases the formation of
unconjugated bilirubin and exceeds the conjugation ability of the liver, causing blood
levels of unconjugated bilirubin to rise.
NURSING GOAL: After rendering nursing interventions, the patient will be able to
engage in behavior changes to increase level of ease
INTERVENTION RATIONALE
After 30 minutes to 1 hour of nursing intervention
Determine the type of discomfort the

client is experiencing such as physical


A comfort scale is similar to pain scale
pain, feeling of discontent, and lack of
and can help the client identify the focus
ease with self or inability to rise above
of discomfort
one’s pain. Have the client rate total

comfort using a scale


Establish context in which lack of comfort

is realized:

 Lack of control may be related to

 Determine how the client is other issues or emotions such as

managing pain and pain fear, loneliness or anxiety.

components

 Determine the client’s  An aspect that can be manipulated

environment both respects privacy in order to enhance comfort

and provides natural lighting with

readily accessible view to


outdoors

 This considers client or family


 Validate the support system’s
needs in the area and show
understanding of the client’s
appreciation for their desires
condition and on-going methods in

order to manage the condition as

appropriate
Review knowledge base and coping skill
This brings these to client’s awareness
that have been used previously to
and promotes use in the current situation
change behavior or promote well-being
Acknowledge the client’s strength in the To be aware on the client’s capabilities in

present situation coping up with the situation


Collaborate in treating or managing

medical conditions involving oxygenation,


To promote physical stability
elimination, mobility, cognitive abilities

and electrolyte balance


Review medication and treatment To determine possible changes or

regimen options to reduce side effects


Suggest that the parent be present
To comfort the child
during procedure
Provide age -appropriate comfort To provide non-pharmacological pain

measures management
Assist the client and modify medication To make the best use of pharmacological

regimen pain or symptom management


Encourage to allow individual adequate
To prevent fatigue
rest periods
Interact with the client in a therapeutic The nurse could be the most important

manner comfort intervention for meeting client’s


needs.

NURSING EVALUATION: After 45 minutes to 1 hour of rendering nursing


interventions, the patient is able to engage in behavior changes to increase
level of ease

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