NURSING CARE FOR ONE PUERPERA BASED ON THE THEORY OF COMFORT

This study aimed at applying and describing the systematic process of nursing care directed to one puerpera. This case study type research had information collected by means of a clinical interview, physical examination, and consultation to medical records as well as direct observation recorded in a field journal. After data collection, the nursing diagnoses, expected outcomes, and nursing interventions were established. The study was based on the theory of comfort. As a criterion for inclusion, the puerpera should demonstrate some need for comfort according to the chosen theory to support the study. The worked diagnoses were: activity intolerance; sleep deprivation; acute pain; and impaired comfort. The fundamental care in this theory allows the nurse to identify the needs of comfort and define interventions to satisfy them. The study was adequate in the care of puerperae.


INTRODUCTION
Nursing care targeted at the women's health should take into account the changes in contemporary society in which the woman is more participant in the labor market and also more autonomous in relation to decisions involving the health-disease process.
.2 It is up to the nurse to assist her during the initial transition to motherhood and monitor her recovery as well as to identify and control any process deviations that may occur.
It is believed that the Systematization of Nursing Care (SAE) based on the NANDA-I, 3 Nursing Results (NOC), 4 and Nursing Interventions (NIC) 5 Classifications is critical to the organization of service, detection of affected human needs, and identification of needs for intervention.When using the SAE, the nurse ensures professional autonomy, develops skills and abilities to reason critically, and ensures care backed by scientific knowledge and directed to the satisfaction of the puerperae's needs.
To provide quality care, the nurse needs to support the SAE in a theory of its own because the theory systematizes the knowledge and organizes the care through its body of knowledge.With the emergence of nursing theories, nursing has been established as a science because theories are considered products of sciences and give relevance to the practice. 6he theory of comfort offers tools to promote nursing care to the puerpera to ensure the fulfillment of her real needs during this period.Comfort in nursing practices is the satisfaction of basic human needs for tranquility (state of calmness or contentment), relief (condition of a person who had a specific need met), or transcendence (condition in which the individual overcome their problems and sufferings) in four contexts of experiences: physical, psychospiritual, social, and environmental. 7,8iven the above, the following guiding questions arose: what are the comfort needs presented by one puerpera and how to satisfy them through the NANDA-I, NOC, and NIC classifications?
The study is justified by allowing the strengthening and enrichment of professional practice through the application of the SAE based on a theory, confirming the respect and commitment to the puerpera in the reach of her well-being and promotion of comfort.Thus, this study had as objectives to apply and describe the systematic process of caring in nursing, based on the theory of comfort, and directed to one puerpera.

METHODOLOGY
Case study with an inpatient puerpera in a hospital that is the reference for humanized childbirth in the city of Fortaleza, Ceará.Case studies offer a good opportunity to promote better understanding of this theory, assisting in sharing and understanding other people's experiences in order to allow the development of a body of knowledge on an issue and advance theoretical and practical analyses. 9fter project approval by the Research Ethics Committee of the Ceará State University, under Opinion No. 11517349, the puerpera was invited to participate in the study, which complied with all ethical precepts of research with humans.After being informed about the study, she signed an informed consent according to Resolution 196/96. 10ata collection occurred in the months of November and December of 2011.The information was collected by means of a clinical interview for data survey, physical examination, and consultation of medical records as well as direct observation at the time of data collection, which was recorded in a field journal.The data were obtained in the said hospital, still during immediate puerperium (the eighth day of hospitalization) at a time chosen by the puerpera, respecting her wishes and privacy.
The inclusion criteria were: being over 18 year old and demonstrate the need for comfort according to the chosen theory to support the study.This case was chosen because the puerpera was anxious and reported feeling uncomfortable, which prompted the researchers to seek in satisfying her needs of comfort.
The diagnoses were identified by the diagnostic reasoning that involves the interaction of interpersonal processes (communication, data collection and analysis, and decision making), technicians (use of instruments and skills to collect data), and intellectual (use of critical thinking to collect and analyze data and make decisions). 11ursing diagnosis is defined as the clinical judgment on the responses of an individual, family, or community to real or potential health problems/life processes. 3The established and more prevalent diagnoses that guided the nursing care were: activity intolerance; sleep deprivation; acute pain; and impaired comfort.
The expected results were established in the evaluation phase with the purpose of having the puerpera reaching the desired comfort.The results are defined as the state, behavior, or perception of an individual, family, or community measured along a continuum in response to one or more nursing interventions. 4 These were chosen by combining the diagnostic concept with the result concept and querying the relationship of possible outcomes for a given diagnosis found in the NOC. 11ubsequently, in the planning phase, the interventions were established, which are any treatment based on clinical judgment and knowledge conducted by a nurse to improve the results in the patient-client. 5he interventions were selected by comparing the concept of intervention with the concepts of diagnosis and results.The list of diagnoses and its possible interventions in the NIC were

RESULTS
Table 1 shows the nursing diagnoses according to the NANDA-I 3 classification, results according to the NOC 4 classification, and nursing interventions and activities implemented and/or proposed, adopted by the NIC 5 classification.

DISCUSSION
Comfort is the immediate and desirable result from nursing care.Comfort needs are deficits identified by the patient that arise from stressful health situations.Based on the needs of comfort, the nurse implements the measures for comfort to meet the needs of healthcare.When interventions are carried out consistently they correlate with increased comfort, which can promote or facilitate the search for health behaviors. 8he patient is defined as an individual, family, and/or community in need of health care.In turn, the nursing staff is responsible for the assessment of comfort needs in this patient and implementation of comfort measures that meet the identified needs.In addition, after interventions, the nurse reassesses the level of patient comfort.The environment is characterized by external influences (physical, political, institutional), which can be manipulated to increase patient comfort.Finally, health is represented by the ideal function of a patient, facilitated by the attention to the needs of comfort. 8so consulted. 11The collection process and interpretation and analysis of results were based on the theory of comfort. 7

CASE PRESENTATION
Secundipara, with gestational age equivalent to 40 weeks and three days, 25 years old, admitted on 11/22/2011.Cesarean delivery carried out at 11.55 p.m. Female newly born; weight: 3,870 g; height: 51 cm; cephalic perimeter: 35.5 cm; Apgar scale: 8/9.Client in a stable union, education up to high school, housewife, living in her own home, had a household income below the minimum wage (for four people), evangelical and resident in Fortaleza-CE.Was worried and apparently tired, said to be not getting enough sleep due to caring for the newborn.The examination: blood pressure: 130 x 90 mmHg; temperature: 36.8 °C; respiratory rate: 16 breaths/min; pulse: 70 beats/min.Firm and turgid breasts with breast milk ejection to the expression.Effective breastfeeding, correct grip.Satisfactory uterine involution with contracted uterus located 5 cm below the umbilical scar.Presented bleeding in surgical wound the day before, however, when removing the occlusive dressing in the morning, the surgical incision presented favorable healing process and no phlogistic signs.Cleaned, physiological lochia, in small quantities with sera and blood.Good general diet acceptance.Present vesical and intestinal eliminations.Absence of edema in the lower limbs, palpable peripheral pulses, without risk of deep vein thrombosis.

Promotion of physical comfort: pain management
Ensure that the patient receives an accurate analgesia care; Inform about pain, its causes, duration and anticipated discomfort as a result of procedures.
IMPAIRED COMFORT characterized by anxiety, fear, and reports of feeling uncomfortable.

Promotion of psychological comfort: relaxation therapy
Use of a calm and reassuring approach, listening to the patient with care; Create a calm environment and without interruptions, with diffuse lighting and comfortable temperature, whenever possible; Lead to behaviors that are conditioned to produce relaxation such as deep breathing.
In this case study, the increased comfort provided empowerment to the woman to engage in the search for health behaviors.The needs of the client originate from a situation of stimulus and can cause negative tension.The increase in comfort can result in the reduction of negative tensions and engagement in positive tensions. 7uerperium can be considered a stimulus situation that can cause negative tensions because the specificities of the woman's demands in this period are influenced by social expectations concerning the exercise of motherhood. 1 Nursing diagnoses, interventions, and outcomes established for the puerpera, based on the theory of comfort, aimed at meeting the needs of tranquility, relief, and transcendence as proposed by this theory.
It should be noted that the propositions of comfort in this theory are suitable to the puerpera in this study: nurses identified the patient's comfort needs; defined interventions to meet the identified needs; when interventions are provided effectively and, therefore, comfort is achieved, they are called comfort measures. 7he theory of comfort is perfectly applicable to puerperae with the SAE because they experience times of stress in the care of their newborns and discomforts from postpartum and relegate their needs to satisfy the needs of the child.At this moment, the nurse identifies the woman's comfort needs and defines comfort measures that satisfy her needs as a priority, and also those from the newborn, in order to promote the mother's comfort.
The understanding of comfort can promote nursing care in the four contexts of experiences: physical -relating to bodily sensations and functions (body repositioning); psychospiritual -relating to self-esteem, self-concept, sexuality, meanings and relationships with an order or higher being (accommodation of religious practices); social -relating to the family, social, and interpersonal relationships to promote the continuity of care; and environmental -relating to the external (reduction of lights, noises). 7n relation to the diagnosis of activity intolerance, the need for achieved comfort belongs to the physical context (body sensations).The proposed interventions aimed at promoting physical comfort through the control of the environment and pain.
Among the needs of environmental comfort is the nursing diagnosis of sleep deprivation.In a study conducted in Goiânia, insomnia was identified in 52.5% of puerperae. 12The exterior scenario for human experiments are in this context (light, noise, temperature), which are comfort influencers that were also identified in hospitals in Rio de Janeiro. 13Thus, the interventions were proposed to eliminate those factors causing discomfort by adopting measures of comfort.
Comfort requires considering a favorable environment as a prime condition in which the person feel cared for, that is cozy and enables relief, security, protection, and well-being. 14Nurses need to strive to provide a pleasant environment with resources for the relief of pain, and be prepared to offer comfort options. 15rotective gestures in the abdominal area and verbal reports revealed the diagnosis of acute pain, also present in 47.5% of puerperae, which has harmful biological agents as related factors, among them: surgical incision from the Cesarean delivery. 12The following were undertaken to promote the physical and psychological comfort to the puerpera: administration of analgesics, promotion of pain relief, and simple relaxation therapy, therefore increasing the patient's comfort level.
The combination of all the negative tensions affecting the puerpera allowed the identification of the diagnosis of impaired comfort demonstrating the need for interventions that favored the relief of pain and discomfort in general in addition to overcoming the patient's concerns.
The most important part of the theory of comfort is the outcome experienced by the puerpera and the evaluation by the nurse.If the level of comfort increases, the nurse can choose to stay with the same plan.If the comfort level does not change as expected, the nurse can try something new or reevaluate the woman's comfort needs.Another important factor in comfort care is that, when the puerpera feels that a comfort level has been achieved, her sense of accomplishment and health search is positively affected. 16he SAE, based on this theory, enables a constant evaluation of implemented interventions, so that they can be maintained or altered if the expected results have not been achieved.It is also possible to reassess the needs of comfort that, in the case of the studied puerpera, constantly changed as the body returns to the pre-pregnancy state.The use of SAE provides directed assistance, individualized and based on scientific knowledge, endorsing nursing and ratifying it as a science.

FINAL CONSIDER ATIONS
The case study showed that the use of the systematic process of caring with the NANDA-I, NOC, and NIC classifications strengthens and enriches the professional practice because it facilitates communication, directs the assistance, and promotes care with effectiveness and efficacy ensuring professional autonomy when facing decisions and adopted actions.
The study has contributed to the enrichment of knowledge in nursing as it showed that the theory of comfort is suitable for the care of puerperae.In this situation, in which often the newborn care is prioritized while the woman stays in the background, the SAE, based on that theory, allowed the identification of the puerpera's comfort needs, which is the protagonist of the care at the moment, and to seek measures of comfort to satisfy them.Thus, the objective of this study was achieved to the extent that it showed that the application of the SAE based on the theory of comfort allowed the implementation of directed and effective comfort measures such as offering adequate information about the puerperal period and providing a favorable environment for resting and relief.The comfort was achieved when the puerpera demonstrated feeling safer in relation to her situation and adopted measures of comfort that enabled the relief of pain and promoted more comfortable sleep.
However, the study presented limitations for having been conducted with just one puerpera, leading to the need for other studies including more puerperae in other situations, such as natural childbirth and related diseases, to ratify the effectiveness of using this theory in the promotion of comfort and satisfaction for their needs.

Table 1 -
Systematization of the nursing care applied to the studied puerpera.Fortaleza, CE, 2013