INTRODUCTION

Caring for the patient hospitalized in an intensive care unit is based on a complex diagnosis and treatment plan. The multiplicity of problems that the patient faces, due to the physiological changes of the pathological process, challenges health professionals to an holistic approach. Not always a traditional and / or conventional approach to the problems of the one who is the target of intensive care, is able to respond to their needs.

In the perspective of better caring for the patient, meeting their basic human needs, nurses are asked to adopt a strategy that responds to the demands of society and the state of the art. The use of a theoretical framework in the design of the nursing care plan is a key element. The experience of a process of critical illness, in which the surrounding environment is characterized by a multiplicity of technological equipment, can put human caring in the risk.

Hospitalization of the critical patient is a process fraught with fragile experiences, given the exposure to stress and threats (bodily integrity, shame, pain, fatigue, separation, dependency and other deprivation). The health priorities of hospitalized patients focus on the treatment of the disease, exposing it to functional decline. ¹

In the process of assistance of the critical patient, the presence of the elderly beneficiary of the intensive care is more and more frequent. That population needs a more systematic evaluation, given their loss of capacity to adapt to stress and illness. Inability to adapt causes a significant risk of functional decline after discharge. ²

The impact of co-morbilities in the elderly critically ill patients, and their reduced physiological readaptation implies the recurrent use of health institutions, whose costs are often significantly higher compared to other age groups. ³

The context of intensive care is characterized by the differentiation of multidisciplinary teams, aiming to the prevention, diagnosis and treatment of potentially reversible situations of critical illness in patients who present failure of one or more vital functions. ⁴ They demand more intensive and vigilant nursing care. ²

The Nurse`s role is of extreme importance in meeting the needs, in the empowerment and readaptation of the capacities and in the guarantee of the dignity of the patient. Comfort is an area of relevant attention for nursing, characterized by the sensation of physical tranquility and physical well-being. ⁵ Comfort can be of the type of relief, tranquility, and transcendence. It is a holistic experience of the person after receiving comfort measures. ¹,^{6 7}-⁸

The process of comfort of the patient is made from the interaction between the professional, the context and the desire of it to happen. This process is characterized by the holistic view of the person and health planning in partnership with the patient / family and other actors, based on commitment, intentionality and mutuality. The patient's dependence, fragility and vulnerability, that characterizes the elderly, compromise the nurse in comforting actions.¹

In this perspective, we have proposed to investigate: What are the comfort needs of the adult and elderly patient in intensive care? What measures promote the comfort of the adult and elderly patient in intensive care?

MATERIAL AND METHOD

Evidence-based practice allows for informed decision-making, contributing to improving the quality of care. ⁹,¹⁰ The integrative review aims at the analysis of intellectual production, synthesizing the state of knowledge of a given theme, pointing out solutions and knowledge gaps. According to the experts consulted, the construction of the integrative review involves six stages, by which we will guide the construction of this review. ^{11 12 13}-¹⁴

The objective of this integrative review is to identify the needs and comfort measures of the adult and elderly patient admitted to intensive care.

In the first step, we construct the research question, using the PI [C] OD method: participants, intervention, (comparison), outcomes and design. ¹¹,¹⁵

To use a unique terminology in the literature search, the Portuguese descriptors were consulted in DeCS ¹⁶ and after their translation into English they were searched in MeSH ¹⁷. The descriptors used for this study are: patient, comfort, well-being, critical care, intensive care, nursing, nursing care, critical care nursing, intensive care nursing.

The sampling process was elaborated in step 2, with the establishment of the inclusion and exclusion criteria for this review, presented in the Table 1.

Tabla 1 Inclusion and exclusion criteria 

Given the nature of the integrative review, the largest number of databases were consulted. For the accomplishment of the research was outlined a Boolean research strategy: [patient] and [Comfort (or) well-being] and [critical care (or) intensive care] and [nursing (or) nursing care (or) critical care nursing (or) intensive care nursing]. In the [Comfort (or) well-being] search the subject field of the search engine was selected, while for the other terms a free search was maintained throughout the document.

The database search was conducted from the 15th to the 25th of May 2016, in the following database search engines: EBSCO (CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection: Comprehensive, Database of Abstracts of Reviews of Effects , Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Library, Information Science & Technology Abstracts, Medication, Health Technology Assessments, NHS Economic Evaluation Database): 278 articles; PubMed: 4894 articles; B-ON: 656 articles; Scientific Repository of Open Access in Portugal: 421 articles; Virtual Health Library: 38 articles; Cochrane Library: 147 articles; and SciELO: 54 articles. After applying the inclusion and exclusion criteria, 10 articles were selected, representing the sample.

The third step allows the organization and summarization of the information in the articles. The items in Table 2, previously prepared, after reading the articles, were used to obtain the relevant data, which includes: source, title of the article, authors, periodical (Vol, nº, year page) and purpose of the study.

In step 4, a critical analysis of the selected articles was carried out, and a support instrument (Table 3) was elaborated with the following information: name of the study, sample, type of research, method of analysis, main results and level of evidence. To have a hierarchical image of knowledge, the studies were classified according to the level of evidence, by the pyramid proposed by Polit. ¹⁰⁾

Tabla 2 Summary of general information  

Tabla 3 Evaluation of the sample 

With the information provided in the articles on comfort care, which constitutes the documentary corpus, contents were analyzed with the support of the NVivo 11 software. ^{18 19}-²⁰ The needs and comfort measures were outlined for categorization, recommended by Kolcaba.⁶ The recording units will correspond to the needs of the elderly in a critical situation, and to the measures adopted to obtain comfort.

In the penultimate stage, the results will be discussed, where the data will be compared with the theoretical assumptions. We may be able to identify possible gaps in knowledge and suggest future studies. Biases that may compromise reported results will be identified.

Finally, we will proceed to the synthesis of knowledge about the needs and comfort measures of the adult and elderly patient in the context of intensive care, in the form of a schematic figure (1 and 2).

RESULTS AND DISCUSSION

The analysis and discussion of data allows the identification of the relevant content of the primary studies. We begin the discussion with the presentation of the synthesis of the data collected, in Table 3 which summarizes each article and its impact to the practice based on evidence.,

From the hierarchical pyramid of evidence, we found that 50% of the studies presented have low strength of evidence, they are at level VI, while 20% are near the top, at level II. Given the fact presented, the recommendations that may arise, should always be submitted to a process of reflection and critical discussion.

In the studies presented, the researchers are mostly Nurses. There is participation of Physicians in 3 studies and in one study the presence of 1 Respiratory Kinesiotherapy Therapist. The inclusion of other professionals in the researches enriches the study of the object, due to the multidisciplinary character introduced. Not all studies are clear as to the authors' affiliation. However, it is possible to verify the participation of researchers with affiliation in the clinical domain of intensive care and academic domain. These facts are an asset in the critical evaluation of the scientific articles, as to the authors' credibility in the research, either through clinical knowledge or through the knowledge of the methodological research presuppositions. These results are in line with the findings of Ramos et al²¹, who report that comfort is an important factor in patient well-being and is a shared responsibility of the hospital's multidisciplinary team.

Of the 10 articles under analysis, 80% were published in journals that address critical care (3 in the nursing journals, 1 in medical and the others in multidisciplinary ones). Two articles were published in health care quality journals.

The methodological options of the articles under analysis (described in table 3) are balanced, given that 40% followed the qualitative paradigm and 60% the quantitative one. In the evaluation of needs and measures of comfort of the elderly, naturalistic thinking deepens, on one hand the knowledge of the nature of the object, but on the other implies the loss of strength in the recommendations for practice based on evidence.

In the sum of the studies, we observed that 780 patients in intensive care, aged 18-90 years, and 183 nurses who provide care, in an intensive care unit were studied. It is verified that the studies were carried out in Europe, Asia and America.

During the identification of biases that may interfere with the results, we must refer to the themes addressed by them. In 50% of the studies, comfort was addressed in the scope of mechanical ventilation. We understand that the synthesis of knowledge performed in this integrative review, is influenced by the problems associated with mechanical ventilation, does not detract this study, it only reduces its amplitude.

According to the Kolcaba Comfort Theory, there are four contexts in which comfort occurs: physical, psycho-spiritual, environmental and sociocultural.⁶ In the studies analyzed, comfort needs were identified and the measures that promote it, through the technique of content analysis (results can be seen in 1 and 2).

Comfort needs, must be read as health care needs. They result from tensions experienced by the person in the health / illness process, causing him problems that require comfort. ^{6 7}-⁸

Figure 1 Comfort Needs 

According to the Kolcaba Comfort Theory, nursing care addresses the needs for comfort, and is not met by traditional support systems. Needs can be physical, psycho-spiritual, social and environmental. ^{6 7}-⁸

From the content analysis, 28 recording units were identified within the scope of comfort needs. Registration units translate into specific care needs. Each subcategory of content analysis represents the context from which needs emerge. Thus, 28% of the needs emerge from the physical context, 14% from the environmental and 14% from the social, while 56% from the identified needs, arise from the psycho-spiritual context.

In the context of intensive care, the most mentioned needs within primary studies are: pain, anxiety, fear, frustration, loss of autonomy, mechanical ventilation and visits of family and friends. These results are corroborated by Blanca et al²² (2008) and Cidália et al²³ (2011), with similar studies on the experiences of the patients hospitalized in intensive care, which identified the traumatic sensations experienced by patients and families, the scarcity of information, the need for personalized attention, the presence of invasive devices and an unnatural environment.

Nurses are asked to identify comfort needs, plan and implement measures, and reassess them after implementation. The evaluation may be subjective or objective, of the patient. ^{(6 7}-⁸ Therefore, comfort measures should be nursing actions, to address the patient's comfort needs, in a holistic and dynamic perspective.

The measures of comfort for the adult and elderly patient are aimed at the relief of discomfort, elimination of stressors, spiritual and family support, and to guarantee hope in hospital life.²⁴

Figure 2 Comfort measures 

Of the articles under study, comfort measures promoting tranquility were the most implemented. In the category of comfort measures, 27 registry units were identified, representing the nursing interventions. Of all the measures of comfort, 18% promote relief, 56% tranquility and 26% transcendence.

The management of measures for pain relief were the most used in the studies analyzed. Gélinas²⁵ identifies non-pharmacological measures as effective, safe and low-cost measures for pain relief, with full autonomy of intensive care nurses, in complementarity with pharmacological treatment.

In the context of comfort measures promoting tranquility, it was evidenced that the management of sedative pharmacological measures, information provided to patients and help to maintain hope, are the most enunciated by the studies. The transmission of information was identified by Pott et al²⁶ as a strategy of comfort, fundamental in the provision of humanized care. The strategies facilitating the different self-care were mencioned by Silva & Valente Ribeiro (2015) 27 and Carvajal Carrascal et al²⁸ as promoters of the patient's comfort.

In transcendent comfort, there is no solid scientific production, but the measures listed, are focused on respect for the individuality and dignity of the patient.

Pain, fear, insecurity, loss of autonomy and loneliness are problems that are often present in the patient admitted to intensive care. The measures implemented agree with the findings in the bibliography ²⁴ and they are the relief of pain, the prevention of suffering, the maintenance of hope, respect for the person, the guarantee of dignity and family involvement, among others.

Another analysis taken out of this integrative review, is related to the theme addressed by the primary studies: the comfort of patients undergoing mechanical ventilation. The comfort needs arising from the use of artificial ventilation, anxiety, restlessness and respiratory stress and the use of comfort measures, such as the management of pharmacological measures of sedation, information to the patient, among others, are in consonance.

CONCLUSION

After completing the integrative review, we could answer the research questions based on the assumptions of Kolcaba Comfort Theory and the Nature Theory of the Comfort Process of the Elderly from Sousa.¹ The collection of data did not suppress all our expectations for this study, however, revealed opportunities for research and reflection on the comfort of the elderly in intensive care.

We could define, through the critical analysis of the articles, the disciplines that care about the phenomenon of comfort, of which Nursing is highlighted, with a preponderant role, both in the creation of a theoretical framework and in the practical approach to comfort.

The patient's comfort needs essentially derive from the experienced physical and psycho-spiritual context. For the patient, the intensive care environment involves the unknown, away from its natural context, surrounded by complex technological systems and with a high probability of iatrogenic corporal and psychiatric injuries resulting from the therapeutic plan.

Internment in intensive care involves a mist of feelings of insecurity, pain, suffering and anxiety, which induce the critical patient the discomfort.

Scientific evidence shows that the most implemented comfort measures are aimed to promote relief and tranquility. From the comfort promotion strategies analyzed, the ones that posess consensus in the primary studies analyzed are: analgesia / sedation management, passive exercise and the implementation of structured information programs.

This study, enriches the knowledge regarding the process of comfort provided to the patient in the context of intensive care. However, the scientific production so far, is sparse. It is plausible to recommend to Nurses, reflection on the theoretical assumptions of Katherine Kolcaba and Sousa, and research on patient care in specific contexts. In this way, it will be possible to build a sustained core of comfort measures that respond effectively to health care needs.