Application of the Theory of Unpleasant Symptoms


The Application of the Theory of Unpleasant Symptoms In Pediatric Nursing Practice

  • Krista Kelly


Every human being regardless of age, ethnicity, socioeconomic status or physical ability will experience pain or unpleasant symptoms at some point in their lives. Pain can be defined as an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue damage (International Association for the Study of Pain, Subcommittee on Taxonomy, 2008). This definition acknowledges not only the physical nature of the pain experience, but also recognizes the psychological aspect. Pain is a highly subjective experience and can only be accurately described by the person experiencing it. According to the Registered Nurses Association of Ontario (2013), nurses have an ethical responsibility for assessing and alleviating pain using appropriate, evidence informed pain management. It also states that nurses are also obligated to advocate for change in the care plan when pain relief is inadequate.

The theory of unpleasant symptoms (TOUS) is a middle-range theory that was developed by nurses to enhance the understanding of relationships among multiple symptoms and symptom experiences to manage unpleasant symptoms through effective interventions (Lee, Vincent & Finnegan, 2017). The TOUS has three major concepts that will be discussed in further detail throughout this paper. The purpose of this paper is to describe, analyze and evaluate the TOUS and its relevance to pediatric nursing practice. This paper will identify a clinical situation on a pediatric unit and will indicate how the TOUS provides direction for guiding nursing practices. Lastly, this paper will assess the utility, strengths and weaknesses of the TOUS.

Description of Theory

According to Smith & Parker (2010), theories help guide our actions, help us reach desired results and give evidence to what has been previously achieved. Specifically, middle-range theories are abstract, yet are concrete enough that it provides a link between nursing research and practice. The middle-range theory of unpleasant symptoms was introduced in 1995 as a means for incorporating existing information about a variety of symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997).

The TOUS incorporates three major components: the symptoms that a patient is undergoing, the factors that influence symptoms and that give rise to the nature of the symptoms, and the effects of the symptom experience. Each individual symptom is considered a multidimensional experience that can be measured together with other symptoms or measured independently (Lopes- Junior, de Omena Bomfim, Nascimento, Pereira-da-Silva, & Garcia de Lima, 2015). Although symptoms differ from one another, they share four common domains including: duration, intensity, quality and distress.

The duration of a symptom refers to the time that the symptom occurs at, or the frequency of the symptom. Intensity indicates the severity, strength or amount of the symptom being experienced by the individual. Whereas, the quality of pain can be used to describe what the symptom feels like to the individual. For instance, pain can be described as sharp, dull, achy or throbbing. Lastly, the distress domain of the symptom experience refers to the degree to which the patient is bothered by it (Lee et al., 2017). The same symptom may be unbearable to some individuals but could be much less severe to others. Thus, it is important to ask patients how much they are bothered by the symptom to gain a better understanding of how they are interpreting the experience and the meaning they associate with it (Lenz, et al.,1997).
In the TOUS, there are three factors that influence each of the previously mentioned domains: physiologic factors, psychologic factors and situational factors (Lenz, Suppe, Gift, Pugh, & Milligan, 1995). Physiologic factors include the normal functioning of the body systems, the presence of any pathology and the individual’s energy levels. Psychologic factors incorporate the individual’s mental state and their reaction to their illness. Lastly, situational factors pertain to aspects of the individual’s physical and social environment that can affect their experience and reporting of symptoms. Examples of social environment include: lifestyle behaviours, social support, employment status, and access to health care services. On the contrary, physical environments can include but are not limited to variables such as noise, light, temperature and polluted air/water; all of which can influence symptoms (Lenz & Pugh, 2014).

According to Lenz & Pugh (2014), the outcome concept in the TOUS is performance. Performance refers to the outcome or effect of the symptom experience and how it impacts the individual’s functional status, cognitive functioning and physical performance. For example, certain symptoms may affect an individual’s ability to perform the activities of daily living or may alter their memory, concentration or problem solving skills (Lee et al., 2017).

Application to Clinical Practice

The assessment and management of pain or unpleasant symptoms are essential skills while dealing with the pediatric population. With children, especially infants and toddlers who are unable to communicate, it can be extremely challenging to identify the presence of pain, which in turn makes it difficult to treat. Therefore, it is important to assess pain by receiving input from the child and their parents or care givers. In the case when a child is unable to communicate, their family and caregivers should be able to advocate for suitable interventions to manage pain based on what they know about their child and the current situation (RNAO, 2013).

The TOUS exemplifies a perspective that not only includes the physical domain of the human experience, but also recognizes the importance influence of psychological and situational factors, as well as their interaction on the symptom experience (Lenz & Pugh, 2014). The writer was able to apply this theory in the pediatric setting while caring for an eight year-old female patient who was experiencing painful urination and abdominal pain related to a urinary tract infection. Looking at the physiological factors, this patient had a history of a fever for the past month, lower abdominal pain and a decreased appetite; otherwise her diet was classified as tolerated. Regarding the psychological factors, the patient expressed she was happy, as she was being discharged that afternoon. While the writer was taking vital signs, the patient was alert, oriented, compliant and aware of why she was in the hospital. As the writer was providing care for this patient, it was evident that there was support from her father, mother and little brother, all who provided positive words of encouragement to get well soon.

The updated version of the TOUS states that symptoms can occur alone or simultaneously, thus this paper will focus on multiple symptoms experienced by the patient; painful urination and abdominal pain. The patient expressed that she experienced a burning and painful sensation while urinating and that it had been occurring for the previous four days. When asked to rate her pain on a severity scale from 0-10, she rated her pain as a 4. In regards to the distress of her symptom, she mentioned it really bothered her during the night, as she was frequently waking up with the urge to urinate. In regards to the patient’s performance, she was unable to fulfill her social role as a grade four student, piano student and dance student as she stayed in the hospital for five days. She was also unable to assist her mother and father in playing/ taking care of her younger brother as she was experiencing abdominal pain that restricted her from doing so.

The TOUS is valuable tool for nurses as it helps collect the previously mentioned data, which in turn helps nurses individualize interventions that fit the patient’s needs and unique pattern of symptoms (Lenz, et al.,1997). In order to manage symptoms effectively, these nursing interventions should include the evaluation of the symptoms individually and as a whole in order to comprehend their interactions (Lopes-Junior et al., 2015). Understanding symptoms of patients is important because experiencing multiple simultaneously occurring symptoms, as opposed to one symptom can have more negative effects on patient outcomes. Ultimately, understanding these multiple symptoms can help improve clinical management of an illness or disease (Lee et al., 2017).

Assessment of Overall Utility

There are both strengths and weaknesses in the utility of the TOUS. The TOUS can be used to improve the understanding of the symptom experience of individuals in various scenarios and provides information that is useful for nursing interventions that can decrease, prevent or manage negative symptoms and their unpleasant effects (Lenz & Pugh, 2014). However, the TOUS lacks detail that may be useful in working with a specific symptom or illness in a given clinical population, such as pediatrics. Specifically, the TOUS has focused only on subjectively perceived symptoms rather than objective observable data. Neonates, infants and toddlers or children who are cognitively impaired, are incapable of verbalizing their pain. Therefore, pain or unpleasant symptom assessment should also be based on behavioural and physiological cues rather than just subjective information. For example, an infant may display pain by frowning or clenching their jaw and crying uncontrollably. They may moan, whimper or have a difficult time being consoled by a parent or caregiver. Being agitated, squirmy or rigid can also be indicative of pain or unpleasant feelings in infants and should be noted (Merkel, Voepel-Lewis, Shayevitz & Malviya, 1997).

The TOUS does an excellent job at looking at the individual in a holistic manner, such that it considers the interactions between individuals and their environment, the multidimensionality of symptom experiences of the individual and uses a biopsychosocial approach (Lee et al., 2017). While constructing an individualistic health care plan for patients, the TOUS does not include an intervention component within the model. This may indicate that the theory is more useful for observing concepts, examining their relationships, and developing tools to measure the concepts/relationships than for developing specific interventions for particular symptoms (Lenz, et al.,1997). In the future, the theory should include suggestions for interventions on specific symptoms for health care providers to use in practice.


The purpose of this paper was to describe, analyze and evaluate the TOUS in a clinical pediatric setting and its connection to nursing practice. The uses, strengths and weaknesses of the theory were also presented. The TOUS is a middle-range theory that emphasizes the importance for nurses to understand that physiological, psychological and situational factors can influence multiple symptoms, which in turn can affect the individual’s performance. It is also critical to realize that the performance outcomes can loop back to impact the symptom experience itself, as well as to alter the influencing factors (Lee et al., 2017). Overall, this theory can be applied in different settings to understand symptoms of individuals, however specific nursing interventions are currently lacking in this theory. With continued research and studies, this theory can only increase in its practicality to health care professionals and caregivers.


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