NR 520 Week 3 Applied Theory Case, Comfort Theory Example

Applied Theory Case: What Kolcaba's Comfort Theory Actually Did in the First Hour of Caring for an 84-Year-Old Who Needed Her Potassium Checked, and Where It Fell Silent

Student Name

College of Nursing, Chamberlain University

NR 520: Applied Theoretical Foundations, Scientific Inquiry, and Decision-Making

Instructor Name

Month Day, Year

Applied Theory Case: What Kolcaba's Comfort Theory Actually Did in the First Hour of Caring for an 84-Year-Old Who Needed Her Potassium Checked, and Where It Fell Silent

The Situation

Mrs. T., 84, was admitted to our medical unit with worsening heart failure. She was receiving intravenous furosemide twice daily, and her potassium had fallen from 4.1 to 3.4 mmol/L over two days, so her physician ordered a basic metabolic panel every morning while diuresis continued. Unlike many daily labs on our unit, this one had a clear reason. She wore hearing aids, was frightened of the dark, and on her first night had become confused and tried to leave her bed after being woken at 0400 for blood. Her son asked the night nurse whether his mother's confusion was "the start of dementia." I was her night nurse on her third night and chose to work through the case using Kolcaba's theory of comfort.

What the Framework Made Me Ask

Kolcaba asks the nurse to look for unmet needs of three kinds, for relief, for ease and for transcendence, in four areas of a patient's life: the body, the mind and spirit, relationships and culture, and the surroundings (Kolcaba, 2001). Working through those contexts changed the questions I asked in the first hour.

Physical. Instead of asking only whether her potassium would be drawn, I asked what her usual sleep was. Her son said she went to bed at 2200 and woke at 0600 every day of her adult life. A 0400 draw landed in the middle of her deepest sleep.

Psychospiritual. I asked what frightened her. She said being woken in the dark by a stranger with a needle made her think she was being taken somewhere. That explained the first night's confusion better than a new cognitive problem.

Sociocultural. I asked her son what helped her feel safe. He said hearing a familiar voice and having her hearing aids in; she took them out at night, so she could not hear who had come in.

Environmental. I asked what the room was like at 0400. The hallway light was bright, the door open, and the phlebotomist turned on the overhead light to find a vein.

Facts I Would Not Otherwise Have Gathered

Without the framework, I would have known that Mrs. T. needed a potassium level and that she had been confused. With it, I learned her lifelong sleep times, the meaning the 0400 draw had for her, the role of her hearing aids and the specific features of the room that made waking frightening. These facts pointed to changes within a nurse's reach. I called the covering physician, who agreed that a result by 0700 was not essential if the draw happened by 0600, since her furosemide dose was not given until 0900. I arranged with phlebotomy for her draw at 0550, alongside her 0600 vital signs and daily weight, so she was woken once rather than twice. I left a note for the phlebotomist to use the bedside lamp and to wake her by name after I had put in her hearing aids. Her son left a recorded message on his phone telling her where she was, to be played if she woke confused.

What I Would Have Done Without It

It is worth being honest about the counterfactual. Without the framework, my first hour would have followed the routine: confirm the lab order, check that the phlebotomy list included her, and document her confusion from the previous night. If she had become confused again, I would probably have called for a delirium screen and perhaps an as-needed medication for agitation, treating the confusion as a problem inside her rather than a response to how she was woken. None of that would have been wrong by the unit's standards. It would simply have missed the cause the framework uncovered. Her son's question about dementia would have been answered with uncertainty rather than with a specific explanation, and the second night would likely have repeated the first.

What Happened

On her third night, Mrs. T. slept from about 2230 to 0550. She was woken once, recognized me, and did not become confused. Her potassium was 3.6 mmol/L and her supplement dose was adjusted on morning rounds as planned. Her son said she seemed "herself again." One night proves nothing, but it is consistent with what is known about sleep in hospital: patients surveyed on a single night across dozens of Dutch hospitals lost well over an hour of sleep compared with home, and staff were one of the most frequent causes of waking (Wesselius et al., 2018).

Where the Framework Fell Silent

The theory could not answer the most important clinical question: whether her potassium needed checking at all that morning, and whether a result at 0700 rather than 0900 mattered. That was a medical judgment about the pace of her diuresis and the risk of arrhythmia, and comfort theory has nothing to say about it. It also could not tell me how to weigh her comfort against a physician's preference for early results if the physician had refused. And it offered no way to address the unit-wide default that puts almost every patient on the 0400 list. Reviews of repetitive testing argue that many daily labs in stable patients can be stopped (Eaton et al., 2017), but that is a question of evidence and policy, outside the theory's reach.

The framework also risks a kind of false modesty. Because it keeps attention on the individual, it made my changes feel like personal favors to Mrs. T. rather than evidence that the routine itself needed review.

The case also changed my own practice on other patients that week. I began asking every patient on the 0400 list about their usual sleep and hearing aids, and two more patients were moved to the 0600 round after their physicians agreed.

What the Case Shows About the Theory

Kolcaba's theory earned its place in the first hour. It made me ask about sleep habits, fear, hearing and the room, and those questions produced facts that led directly to changes that helped. It did not decide whether the test was needed, and it did not reach the system that scheduled it. Used alone, it would have improved one patient's night. Used alongside clinical judgment and a quality framework, it identified what that improvement required and pointed to the larger question the unit still has to answer.

References

Eaton, K. P., Levy, K., Soong, C., Pahwa, A. K., Petrilli, C., Ziemba, J. B., Cho, H. J., Alban, R., Blanck, J. F., & Parsons, A. S. (2017). Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Internal Medicine, 177(12), 1833-1839. https://doi.org/10.1001/jamainternmed.2017.5152

Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49(2), 86-92. https://doi.org/10.1067/mno.2001.110268

Wesselius, H. M., van den Ende, E. S., Alsma, J., ter Maaten, J. C., Schuit, S. C. E., Stassen, P. M., de Vries, O. J., Kaasjager, K. H. A. H., Haak, H. R., van Doormaal, F. F., Hoogerwerf, J. J., Terwee, C. B., van de Ven, P. M., Bosch, F. H., van Someren, E. J. W., & Nanayakkara, P. W. B. (2018). Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients. JAMA Internal Medicine, 178(9), 1201-1208. https://doi.org/10.1001/jamainternmed.2018.2669