AACN Essentials of Progressive Care

Nursing, Third Edition (Chulay, AACN

Essentials of Progressive Care
Nursing) 3rd Edition, (Ebook PDF)
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vi CONTENTS

13. Hematologic and Immune Systems................................................................................................................................................. 303

Diane K. Dressler
14. Gastrointestinal System..................................................................................................................................................................... 317
Deborah A. Andris, Elizabeth Krzywda, Carol Rees Parrish, and Joe Krenitsky
15. Renal System....................................................................................................................................................................................... 349
Carol Hinkle
16. Endocrine System............................................................................................................................................................................... 365
Christine Kessler
17. Trauma................................................................................................................................................................................................. 381
Allen C. Wolfe and Benjamin C. Hughes

Section III. Advanced Concepts in Caring for the Critically Ill Patient................................................................................................................................. 397
18. Advanced ECG Concepts.................................................................................................................................................................. 399
Carol Jacobson
19. Advanced Cardiovascular Concepts.............................................................................................................................................. 441
Barbara Leeper
20. Advanced Neurologic Concepts....................................................................................................................................................... 469
Dea Mahanes

Section IV. Key Reference Information............................................................................................................................................................................................................. 493

21. Normal Values Table.......................................................................................................................................................................... 495
Suzanne M. Burns
22. Pharmacology Tables......................................................................................................................................................................... 497
Earnest Alexander
23. Advanced Cardiac Life Support Algorithms................................................................................................................................... 511
Suzanne M. Burns
24. Cardiac Rhythms, ECG Characteristics, and Treatment Guide................................................................................................... 515
Carol Jacobson
Index ............................................................................................................................................................................................................... 523
 Contents in Detail

Contributors.............................................................................................................................................................................................................................................................xvii
Reviewers................................................................................................................................................................................................................................................................. xix
Preface................................................................................................................................................................................................................ xxi

Section I.╇ The Essentials........................................................................................................................................................................................... 1

1. Assessment of Progressive Care Patients and Their Families.............................................................................................................. 3
Mary Fran Tracy
Assessment Frameworkâ•… 3
Prearrival Assessment 4 / Arrival Quick Check 4 / Comprehensive Initial Assessment 4 / Ongoing
Assessment 4 / Patient Safety Considerations in Admission Assessments 4
Prearrival Assessment: Before the Action Beginsâ•… 5
Arrival Quick Check Assessmentâ•… 5
Airway and Breathing 6 / Circulation and Cerebral Perfusion 7 / Chief Complaint 7 / Drugs and
Diagnostic Tests 7 / Equipment 7
Comprehensive Initial Assessmentâ•… 8
Past Medical History 9 / Social History 9 / Physical Assessment by Body System 10 / Transition/
Discharge Planning / 15
Ongoing Assessmentâ•… 15
Selected Bibliographyâ•… 16
Progressive Care Assessment 16 / Evidence-Based Practice 16
2. Planning Care for Progressive Care Patients and Their Families...................................................................................................... 17
Mary Fran Tracy
Multidisciplinary Plan of Care â•… 18
Planning Care Through Staffing Considerationsâ•… 18
Patient Safety Considerations in Planning Careâ•… 19
Prevention of Common Complicationsâ•… 20
Physiologic Instability 20 / Deep Venous Thrombosis 20 / Hospital-Acquired Infections 20 /
Skin Breakdown 21 / Sleep Pattern Disturbance 22 / Psychosocial Impact 22
Patient and Family Educationâ•… 24
Assessment of Learning Readiness 24 / Strategies to Address Patient and Family Education 24 /
Outcome Measurement 25
Family-Focused Careâ•… 25
Transporting the Progressive Care Patientâ•… 27
Assessment of Risk for Complications 27 / Level of Care Required During Transport 28 /
Preparation 29 / Transport 30 / Interfacility Transfers 31
Transitioning to the Next Stage of Careâ•… 31
Supporting Patients and Their Families During the Dying Processâ•… 31

vii
viii CONTENTS IN DETAIL

Selected Bibliography 31
Family Interventions/Visitation 31/ Infection Control 32 / Patient and Family Education 32 /
Psychological Problems 32 / Sleep Deprivation 32 / Transport of Critically Ill Patients 32 /
Evidence-Based Practice 32

3. Interpretation and Management of Basic Cardiac Rhythms.......................................................................................................... 33

Carol Jacobson
Basic Electrophysiology 33
ECG Waveforms, Complexes, and Intervals 34
P Wave 34 / QRS Complex 35 / T Wave 35 / U Wave 35 / PR Interval 35 / ST Segment 35 /
QT Interval 35
Basic Electrocardiography 35
Cardiac Monitoring 35
Determination of the Heart Rate 38
Determination of Cardiac Rhythm 38
Common Arrhythmias 39
Rhythms Originating in the Sinus Node 39
Normal Sinus Rhythm 39 / Sinus Bradycardia 39 / Sinus Tachycardia 40 / Sinus Arrhythmia 40 /
Sinus Arrest 40
Arrhythmias Originating in the Atria 41
Premature Atrial Complexes 41 / Wandering Atrial Pacemaker 42 / Atrial Tachycardia 42 / Atrial
Flutter 43 / Atrial Fibrillation 45 / Supraventricular Tachycardia 49
Arrhythmias Originating in the Atrioventricular Junction 50
Premature Junctional Complexes 50 / Junctional Rhythm, Accelerated Junctional Rhythm, and
Junctional Tachycardia 51
Arrhythmias Originating in the Ventricles 51
Premature Ventricular Complexes 51 / Ventricular Rhythm and Accelerated Ventricular Rhythm 52 /
Ventricular Tachycardia 53 / Ventricular Fibrillation 54 / Ventricular Asystole 54
Atrioventricular Blocks 55
First-Degree Atrioventricular Block 55 / Second-Degree Atrioventricular Block 55 / High-Grade
Atrioventricular Block 56 / Third-Degree Atrioventricular Block (Complete Block) 57
Temporary Pacing 58
Indications 58 / Transvenous Pacing 59 / Epicardial Pacing 60 / Components of a Pacing
System 60 / Basics of Pacemaker Operation 60 / Initiating Transvenous Ventricular Pacing 62 /
Initiating Epicardial Pacing 62 / External (Transcutaneous) Pacemakers 62
Defibrillation and Cardioversion 62
Defibrillation 62 / Automatic External Defibrillators 63 / Cardioversion 63
Selected Bibliography 64
Evidence-Based Practice 65

4. Hemodynamic Monitoring................................................................................................................................................................. 67
Leanna R. Miller
Hemodynamic Parameters 67
Cardiac Output 67 / Components of Cardiac Output/Cardiac Index 69 / Stroke Volume and Stroke
Volume Index 70 / Ejection Fraction 70 / Factors Affecting Stroke Volume/Stroke Volume Index 70
Basic Components of Hemodynamic Monitoring Systems 74
Pulmonary Artery Catheter 74 / Arterial Catheter 74 / Pressure Tubing 74 / Pressure Transducer 74 /
Pressure Amplifier 74 / Pressure Bag and Flush Device 74 / Alarms 76
Obtaining Accurate CVP and Arterial Values 76
Zeroing the Transducer 76 / Leveling the Transducer to the Catheter Tip 76 / Calibration of the
Transducer/Amplifier System 77 / Ensuring Accurate Waveform Transmission 77
Insertion and Removal of Catheters 78
Central Venous Catheters 78 / Arterial Catheters 80
Obtaining and Interpreting Hemodynamic Waveforms 81
Patient Positioning 81 / Interpretation 81 / Artifacts in Hemodynamic Waveforms: Respiratory
Influence 85
Continuous Mixed and Central Venous Oxygen Monitoring (Svo2/Scvo2) 86
Svo2/Scvo2 Monitoring Principles 86
Minimally Invasive Hemodynamic Monitoring 87
 CONTENTS IN DETAIL ix

Thoracic Bioimpedance 87 / Pulse Contour Measurement 88

Selected Bibliography 88
Hemodynamic Monitoring 88 / Minimally Invasive Hemodynamic Monitoring 89 /
Therapeutics 90 / Evidence-Based Practice Guidelines 92
5. Airway and Ventilatory Management................................................................................................................................................ 93
Robert E. St. John and Maureen A. Seckel
Tests, Monitoring Systems and Respiratory Assessment Techniques 93
Arterial Blood Gas Monitoring 93 / Venous Blood Gas Monitoring 98 / Pulse Oximetry 98 /
Assessing Pulmonary Function 100
Airway Management 101
Oropharyngeal Airway 101 / Nasopharyngeal Airway 102 / Laryngeal Mask Airway 102 /
Esophageal Tracheal Airway 102 / Artificial Airways 102 / Endotracheal Suctioning 105
Oxygen Therapy 107
Complications 107 / Oxygen Delivery / 107
Basic Ventilatory Management 110
Indications 110 / General Principles 110 / Patient-Ventilator System 111 / Modes 114 /
Complications of Mechanical Ventilation 115 / Weaning From Short-Term Mechanical
Ventilation 117 / Weaning From Long-Term Mechanical Ventilation 119 / Respiratory Fatigue, Rest,
and ­Conditioning 120 / Wean Trial Protocols 121 / Other Protocols for Use 122 / Critical Pathways
122 / Systematic Institutional Initiatives for the Management of the LTMV Patient Population 123 /
Troubleshooting Ventilators 124 / Oral Feedings 124 / Communication 125 / Principles of
­Management 128
Selected Bibliography 129
General Critical Care 129 / Ventilator Management 130 / Weaning From Mechanical Ventilation 130 /
Communication 131 / Evidence-Based Resources 131
6. Pain and Sedation Management....................................................................................................................................................... 133
Yvonne D’Arcy and Suzanne M. Burns
Physiologic Mechanisms of Pain 133
Peripheral Mechanisms 133 / Spinal Cord Integration 134 / Central Processing 134
Responses to Pain 135
Pain Assessment 136
A Multimodal Approach to Pain Management 136
Nonsteroidal Anti-Inflammatory Drugs 136
Side Effects 138
Opioids 138
Side Effects 138 / Intravenous Opioids 139 / Patient-Controlled Analgesia 139 / Switching From IV
to Oral Opioid Analgesia 140
Epidural Analgesia 141
Epidural Opioids 142 / Epidural Local Anesthetics 142
Cutaneous Stimulation 143
Distraction 143
Imagery 143
Relaxation Techniques 144
Deep Breathing and Progressive Relaxation 144 / Presence 145
Special Considerations for Pain Management in the Elderly 145
Assessment 145 / Interventions 145
Sedation 145
Reasons for Sedation 146 / Drugs for Sedation 147 / Drugs for Delirium 147 / Goals of Sedation,
Monitoring, and Management 147
Selected Bibliography 149
Pain Management 149 / Sedation 150 / Evidence-Based Practice Guidelines 150
7. Pharmacology..................................................................................................................................................................................... 151
Earnest Alexander
Medication Safety 151
Medication Administration Methods 152
Intravenous 152/ Intramuscular or Subcutaneous 152 / Oral 152 / Sublingual 153 / Intranasal 153 /
Transdermal 153
Central Nervous System Pharmacology 153
x CONTENTS IN DETAIL

Sedatives 153 / Analgesics 156 / Anticonvulsants 158

Cardiovascular System Pharmacology 161
Miscellaneous Agents 161 / Parenteral Vasodilators 161 / Antiarrhythmics 164 /
Vasodilators and Remodeling Agents 166 / Vasopressor Agents 166 / Inotropic Agents 167
Antibiotic Pharmacology 167
Aminoglycosides 168 / Vancomycin 168
Pulmonary Pharmacology 169
Theophylline 169 / Albuterol 170 / Levalbuterol 170
Gastrointestinal Pharmacology 170
Stress Ulcer Prophylaxis 170 / Acute Peptic Ulcer Bleeding 171 / Variceal Hemorrhage 171
Renal Pharmacology 172
Diuretics 172
Hematologic Pharmacology 173
Anticoagulants 173 / Factor Xa Inhibitors 175 / Direct Thrombin Inhibitors 175 / Glycoprotein IIb/
IIIa Inhibitor 175 / Thrombolytic Agents 176
Immunosuppressive Agents 177
Cyclosporine 177 / Tacrolimus (FK506) 177 / Sirolimus (Rapamycin) 177
Special Dosing Considerations 178
Drug Disposition in the Elderly 178 / Therapeutic Drug Monitoring   178
Selected Bibliography 179
General 179 / Evidence-Based Practice Guidelines 179
8. Ethical and Legal Considerations..................................................................................................................................................... 181
Sarah Delgado
The Foundation for Ethical Decision Making 181
Professional Codes and Standards 181 / Position Statements and Guidelines 182 / Institutional
Policies 182 / Legal Standards 183 / Principles of Ethics 183 / The Ethics of Care 186 / Paternalism 186 /
Patient Advocacy 187
The Process of Ethical Analysis 188
Assessment 188 / Plan 188 / Implementation 188 / Evaluation 188
Contemporary Ethical Issues 188
Informed Consent 188 / Determining Capacity 189 / Advance Directives 189 / End-of-Life
Issues 190 / Resuscitation Decisions 192
Building an Ethical Environment 193
Values Clarification 193 / Provide Information and Clarify Issues 193 / Recognize Moral Distress 194 /
Engage in Collaborative Decision Making 194
Selected Bibliography 194
Professional Codes, Standards, and Position Statements 195 / Evidence-Based Guidelines 195 /
On-line References of Interest: Related to Legal and Ethical Considerations 195

Section II. Pathologic Conditions............................................................................................................................................................................ 197

9. Cardiovascular System....................................................................................................................................................................... 199
Barbara Leeper
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systems 199
Assessment of Chest Pain 199 / Coronary Angiography 199 / Percutaneous Coronary Interventions 202 /
Other Percutaneous Coronary Interventions 202
Pathologic Conditions 203
Acute Ischemic Heart Disease 203 / Electrophysiology Studies 214 / Heart Failure 214 / Shock 221 /
Hypertension 225
Selected Bibliography 228
General Cardiovascular 228 / Coronary Revascularization 228 / Acute Ischemic Heart Disease 228 /
Heart Failure 228 / Shock 228 / Hypertension 229 / Evidence-Based Practice Guidelines 229
10. Respiratory System............................................................................................................................................................................. 231
Maureen A. Seckel
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systems 231
Chest X-Rays 231 / Computed Tomography and Magnetic Resonance Imaging 236 / Pulmonary
Angiograms/CTPA and V/Q Scans 236 / Chest Tubes 237 / Thoracic Surgery and Procedures 237
Pathologic Conditions 238
 CONTENTS IN DETAIL xi

Acute Respiratory Failure 238 / Acute Respiratory Distress Syndrome (ARDS) 243 /
Acute Respiratory Failure in the Patient with Chronic Obstructive Pulmonary Disease 244 /
Acute Respiratory Failure in the Patient with Asthma 247 / Interstitial Lung Disease 250 /
Pulmonary Hypertension 250 / Pneumonia 251 / Pulmonary Embolism 255
Selected Bibliographyâ•… 258
Critical Care Management of Respiratory Problems 258 / Chest X-Ray Interpretation 258 /
Miscellaneous 258 / Evidence-Based Practice Guidelines 258
11. Multisystem Problems....................................................................................................................................................................... 261
Ruth M. Kleinpell
Pathologic Conditionsâ•… 261
Sepsis and Multiple Organ Dysfunction Syndrome 261
Overdosesâ•… 268
Etiology, Risk Factors, and Pathophysiology 268
Complex Wounds and Pressure Ulcersâ•… 273
Pressure Ulcer Stages 273
Healthcare Acquired Infectionsâ•… 274
Selected Infectious Diseasesâ•… 276
Selected Bibliographyâ•… 276
SIRS, Sepsis, and MODS 276 / Overdose 277 / Complex Wounds and Pressure Ulcers 277 /
Healthcare Acquired Infections 278 / Selected Infectious Diseases 278
12. Neurologic System.............................................................................................................................................................................. 279
Dea Mahanes
Special Assessment Techniques and Diagnostic Testsâ•… 279
Level of Consciousness 279 / Glasgow Coma Scale 280 / Full Outline of UnResponsiveness (FOUR)
Score 281 / Mental Status 281 / Motor Assessment 282 / Sensation 283 / Cranial Nerve Assessment
and Assessment of Brain Stem Function 283 / Vital Sign Alterations in Neurologic Dysfunction 285
Diagnostic Testingâ•… 285
Lumbar Puncture 285 / Computed Tomography 287 / Magnetic Resonance Imaging 287 / Cerebral
(Catheter) Angiography 288 / Transcranial Doppler Ultrasound 288 / Electroencephalography 288 /
Electromyography/Nerve Conduction Studies 289
Intracranial Pressure â•… 289
Cerebral Blood Flow 289 / Causes of Increased Intracranial Pressure 289 / Clinical Presentation 291 /
Principles of Management of Increased ICP 291
Acute Ischemic Strokeâ•… 292
Etiology, Risk Factors, and Pathophysiology 292 / Clinical Presentation 293 / Diagnostic Tests 294 /
Principles of Management of Acute Ischemic Stroke 294
Hemorrhagic Strokeâ•… 296
Etiology, Risk Factors, and Pathophysiology 296 / Clinical Presentation 296 / Diagnostic Tests 296 /
Principles of Management of Intracerebral Hemorrhage 296
Seizuresâ•… 297
Etiology, Risk Factors, and Pathophysiology 297 / Clinical Presentation 297 / Diagnostic Testing 298 /
Principles of Management of Seizures 298
Infections of the Central Nervous Systemâ•… 298
Meningitis 298 / Encephalitis 299 / Intracranial Abscess 299
Neuromuscular Diseasesâ•… 299
Myasthenia Gravis 299 / Guillain-Barré Syndrome 299 / Amyotrophic Lateral Sclerosis 299
Selected Bibliographyâ•… 300
Assessment and Diagnostic Testing 300 / Intracranial Pressure 300 / Acute Ischemic Stroke and
Hemorrhagic Stroke 300 / Seizures 300 / Infections of the Central Nervous System 301 /
Neuromuscular Diseases 301 / Evidence-Based Practice 301
13. Hematologic and Immune Systems................................................................................................................................................. 303
Diane K. Dressler
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systemsâ•… 303
Complete Blood Count 303 / Red Blood Cell Count 303 / Hemoglobin 304 / Hematocrit 304 /
Red Blood Cell Indices 304 / Total White Blood Cell Count 304 / White Blood Cell
Differential 305 / Platelet Count 305 / Coagulation Studies 305 / Additional Tests and Procedures 306
Pathologic Conditionsâ•… 306
xii CONTENTS IN DETAIL

Anemia 306 / Immunocompromise 308 / Coagulopathies 310

Selected Bibliographyâ•… 314
Anemia 314 / Immunocompromised Patient 315 / Coagulopathy 315
14. Gastrointestinal System..................................................................................................................................................................... 317
Deborah A. Andris, Elizabeth Krzywda, Carol Rees Parrish, and Joe Krenitsky
Pathologic Conditionsâ•… 317
Acute Upper Gastrointestinal Bleeding 317 / Liver Failure 325 / Acute Pancreatitis 330 / Intestinal
Ischemia 332 / Bowel Obstruction 333 / Bariatric (Weight Loss) Surgery 335 / Surgical Procedures 335
Nutritional Support for Acutely Ill Patientsâ•… 337
Nutrition Requirements 337 / Nutritional Case: Special Populations 337 / Postgastrectomy
Syndromes 338 / Gastric Residual Volume 339 / Aspiration 340 / Bowel Sounds 341 / Nausea and
Vomiting 341 / Osmolality or Hypertonicity of Formula 341 / Diarrhea 342 / Flow Rates and Hours
of Infusion 342 / Formula Selection 343
Selected Bibliographyâ•… 343
Upper GI Bleeding 343 / Liver Failure 344 / Acute Pancreatitis 344 / Intestinal Ischemia/Bowel
Obstruction 344 / Nutrition 345 / On-line References of Interest 347 / Bariatric (Gastric Bypass)
Surgery 347
15. Renal System....................................................................................................................................................................................... 349
Carol Hinkle
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systemsâ•… 349
Pathologic Conditionsâ•… 349
Acute Renal Failure 349 / Life-Threatening Electrolyte Imbalances 354
Renal Replacement Therapyâ•… 358
Access 359 / Dialyzer/Hemofilters/Dialysate 360 / Procedures 360 / Indications for and Efficacy of
Renal Replacement Therapy Modes 362 / General Renal Replacement Therapy Interventions 362
Selected Bibliographyâ•… 363
General Renal and Electrolyte 363 / Renal Failure 363 / Renal Replacement Therapy 363 / Online References 363
16. Endocrine System............................................................................................................................................................................... 365
Christine Kessler
Special Assessment Techniques, Diagnostic Tests, and Monitoring Systemsâ•… 365
Blood Glucose Monitoring 365
Pathologic Conditionsâ•… 367
Hyperglycemic States 367 / Hyperglycemic Emergencies 368 / Acute Hypoglycemia 374 / Syndrome
of Inappropriate Antidiuretic Hormone Secretion 375 / Diabetes Insipidus 377
Selected Bibliographyâ•… 379
Blood Glucose Monitoring 379 / Hyperglycemia, DKA, and HHS 379 / SIADH and Diabetes Insipidus 379
17. Trauma................................................................................................................................................................................................. 381
Allen C. Wolfe and BenjaminW. Hughes
Specialized Assessment Techniques, Diagnostic Tests, and Monitoring Systemsâ•… 381
Primary and Secondary Trauma Survey Assessment 381 / Diagnostic Studies 383 / Mechanism of
Injury 384 / Physiologic Consequences of Trauma 386
Common Injuries in the Trauma Patientâ•… 387
Thoracic Trauma 387 / Abdominal Trauma 390 / Musculoskeletal Trauma 391
Complications of Traumatic Injury in Severe Multisystem
� Trauma╅ 393
Acute Respiratory Distress Syndrome 394 / Infection/Sepsis 394 / Systemic Inflammatory Response
Syndrome 395
Psychological Consequences of Traumaâ•… 395
Selected Bibliographyâ•… 396
General Trauma 396 / Selected Online References 396 / Evidence-Based Practice 396

Section III.╇ Advanced Concepts in Caring for the Critically Ill Patient................................................................................................................................. 397
18. Advanced ECG Concepts.................................................................................................................................................................. 399
Carol Jacobson
The 12-Lead Electrocardiogramâ•… 399
Axis Determination 403 / Bundle Branch Block 404 / Acute Coronary Syndrome 408 / Preexcitation
Syndromes 414
Advanced Arrhythmia Interpretationâ•… 418
 CONTENTS IN DETAIL xiii

Supraventricular Tachycardias 418 / Polymorphic Ventricular Tachycardias 422 / Differentiating

Wide QRS Beats and Rhythms 424
ST-Segment Monitoringâ•… 427
Measuring the ST Segment 427 / Choosing the Best Leads for ST-Segment Monitoring 427
Cardiac Pacemakersâ•… 429
Evaluating Pacemaker Function 431 / VVI Pacemaker Evaluation 431 / DDD Pacemaker Evaluation 434
Selected Bibliographyâ•… 438
Evidence-Based Practice 439
19. Advanced Cardiovascular Concepts................................................................................................................................................ 441
Barbara Leeper
Pathologic Conditionsâ•… 441
Cardiomyopathy 441 / Valvular Heart Disease 446 / Pericarditis 452 / Aortic Aneurysm 454 /
Cardiac Transplantation 458 / Ventricular Assist Devices 463
Selected Bibliographyâ•… 466
General Cardiovascular 466 / Cardiomyopathy 466 / Heart Transplantation 467 / Valvular
Disorders 467 / Pericarditis 467 / Thoraco-Abdominal Aneurysms 467 / Ventricular Assist
Devices 467 / Intraaortic Balloon Pump 468 / Evidence-Based Practice Guidelines 468
20. Advanced Neurologic Concepts....................................................................................................................................................... 469
Dea Mahanes
Subarachnoid Hemorrhageâ•… 469
Etiology, Risk Factors, and Pathophysiology 469 / Clinical Presentation 469 / Diagnostic Tests 470 /
Principles of Management of Aneurysmal Subarachnoid Hemorrhage 471
Traumatic Brain Injuryâ•… 474
Etiology, Risk Factors, and Pathophysiology 474 / Clinical Presentation 476 / Diagnostic Tests 477 /
Principles of Management of Traumatic Brain Injury 477
Traumatic Spinal Cord Injuryâ•… 479
Etiology, Risk Factors, and Pathophysiology 479 / Clinical Presentation 479 / Diagnostic Tests 481 /
Principles of Management of Acute Spinal Cord Injury 481 / Future Spinal Cord Injury Treatment 486
Brain Tumorsâ•… 487
Etiology, Risk Factors, and Pathophysiology 487 / Clinical Presentation 487 / Diagnostic Tests 487 /
Principles of Management of Intracranial Tumors 488 / Special Considerations: Transsphenoidal
Resection of Pituitary Tumors 489
Special Procedures: Invasive Monitoring of Intracranial Pressure â•… 489
Intracranial Pressure Waveforms 490
Special Procedures: Management of a Patient With a Lumbar Drainâ•… 491
Selected Bibliographyâ•… 491
Subarachnoid Hemorrhage 491 / Traumatic Brain Injury 492 / Spinal Cord Injury 492 / Brain
Tumors 492 / Intracranial Pressure Monitoring 492 / Evidence-Based Guidelines 492

Section IV.╇ Key Reference Information............................................................................................................................................................................................................. 493

21. Normal Values Table.......................................................................................................................................................................... 495
Suzanne M. Burns
22. Pharmacology Tables......................................................................................................................................................................... 497
Earnest Alexander
23. Advanced Cardiac Life Support Algorithms................................................................................................................................... 511
Suzanne M. Burns
24. Cardiac Rhythms, ECG Characteristics, and Treatment Guide................................................................................................... 515
Carol Jacobson

Index .................................................................................................................................................................................................................................................................... 523

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 Acknowledgments
Special thanks to those who made contributions to the pre-
vious editions of both the Essentials of Critical Care Nursing
and the Essentials of Progressive Care Nursing.
To Cathie Guzzetta, RN, PhD, FAAN and Barbara
Dossey, RN, MS, FAAN for their early work in creating the
Handbook of Critical Care Nursing which preceded the Essen-
tials of Critical Care Nursing and the Essentials of Progressive
Care Nursing books.
To Marianne Chulay, RN, PhD, FAAN, my dear friend
and colleague, for her many contributions and mentoring
during the development of the first two editions of the Essen-
tials of Critical Care Nursing and the Essentials of Progressive
Care Nursing books. Her inspiration, drive, and thoughtful
approach to the books continue to be an inspiration to me
and the authors with whom she worked.
Thank you to the many authors for their past contributions:
Tom Ahrens, RNS, DNS, CCNS, FAAN (Chapter 4 and
key reference materials)
Sue Simmons-Alling, RN, MSN (Chapter 2)
Suzanne M. Burns, RN, MSN, RRT ACNP, CCRN, FAAN,
FCCM, FAANP (Chapters 4, 5, 11)
Deb Byram, RN, MS (Chapter 1)
Karen Carlson, RN, MN (Chapter 15)
Joan Michiko, Ching RN, MN, CPHQ (Chapter 6)
Marianne Chulay, RN, PhD, FAAN: (Chapter 10, and the
key reference materials)
Maria Connolly, RN, DNSc (Chapters 5, 10)
Dorrie Fontaine, RN, DNSc, FAAN (Chapter 17)
Bradi Granger, RN, PhD (Chapter 9)
Anne Marie Gregoire, RN, MSN, CRNP (Chapter 19)
Joanne Krumberger, RN, MSN, CHE, FAAN (Chapters 14, 16)
Sally Miller, RN, PhD, APN, FAANP (Chapter 14)
Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN (Chapter 17)
Juanita Reigle, RN, MSN, ACNP (Chapter 8)
Anita Sherer, RN, MSN (Chapter 2)
Jamie Sinks, RN, MS (Chapter 17)
Greg Susla, Pharm D, FCCM (Chapters 7 and key reference
materials)
Debbie Tribett, RN, MS, CS, LNP (Chapter 13)
Debra Lynn-McHale Wiegand, RN, PhD, CS (Chapter 19)
Lorie Wild, RN, PhD (Chapter 6)
Susan Woods, PhD, RN (Chapters 3, 18)
Marlene Yates, RN, MSN (Chapter 2)
xv
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 Contibutors

Earnest Alexander, PharmD, FCCM Diane K. Dressler, MSN, RN, CCRN

Assistant Director, Clinical Pharmacy Services Clinical Assistant Professor
Program Director, PGY2 Critical Care Residency Marquette University College of Nursing
Department of Pharmacy Services Milwaukee, Wisconsin
Tampa General Hospital Chapter 13: Hematologic and Immune Systems
Tampa, Florida
Carol Hinkle, MSN, RN-BC
Chapter 7: Pharmacology
Brookwoood Medical Center
Chapter 22: Pharmacology Tables
Birmingham, Alabama
Deborah A. Andris, MSN, APNP Chapter 15: Renal System
Nurse Practitioner
Benjamin W. Hughes, RN, MSN, MS, CCRN
Division of Colorectal Surgery
Director
Medical College of Wisconsin
Trauma Institute and Cardiopulmonary Services
Milwaukee, Wisconsin
University of Louisville Hospital
Chapter 14: Gastrointestinal System
Louisville, Kentucky
Yvonne D’Arcy, MS, CRNP, CNS Chapter 17: Trauma
Pain Management and Palliative Care Nurse Practitioner
Carol Jacobson, RN, MN
Suburban Hospital-Johns Hopkins Medicine
Director, Quality Education Services & Partner
Bethesda, Maryland
Cardiovascular Nursing Education Associates
Chapter 6: Pain and Sedation Management
Clinical Faculty
Suzanne M. Burns, RN, MSN, RRT, ACNP, CCRN, FAAN, University of Washington School of Nursing
FCCM, FAANP Seattle, Washington
Professor Emeritus, School of Nursing Chapter 3: Interpretation and Management of Basic Cardiac
University of Virginia Rhythms
Consultant, Critical and Progressive Care and Clinical Chapter 18: Advanced ECG Concepts
Nursing Research Chapter 24: Cardiac Rhythms, ECG Characteristics, and
Charlottesville, Virginia Treatment Guide
Chapter 6: Pain and Sedation Management
Robert E. St. John, MSN, RN, RRT
Chapter 21: Normal Values Table
Covidien
Chapter 23: Advanced Cardiac Life Support Algorithms
Care Area Manager–US Patient Monitoring
Sarah Delgado, RN, MSN, ACNP Respiratory and Monitoring Solutions
Chronic Care Nurse Practitioner Boulder, Colorado
PIH Health Physicians Chapter 5: Airway and Ventilatory Management
Whittier, California
Chapter 8: Ethical and Legal Considerations

xvii
xviii CONTIBUTORS
Christine Kessler, MN, CNS, ANP, BC-ADM
Nurse Practitioner, Diabetes Institute
Department of Endocrinology and Metabolic Medicine
Walter Reed Army Medical Center
Washington, DC
Chapter 16: Endocrine System
Ruth M. Kleinpell, PhD, RN-CS, FAAN, FCCM, FAANP,
ACNP, CCRN
Director, Center for Clinical Research and Scholarship
Rush University Medical Center
Professor, Rush University College of Nursing
Nurse Practitioner, Our Lady of the Resurrection
�Medical Center
Chicago, Illinois
Chapter 11: Multisystem Problems
Joe Krenitsky, MS, RD
Nutrition Support Specialist
Digestive Health Center of Excellence
Department of Nutrition Services
University of Virginia Health System
Charlottesvillle, Virginia
Chapter 14: Gastrointestinal System
Elizabeth Krzywda, MSN, APNP
Nurse Practitioner
Pancreaticobiliary Surgery Program
Medical College of Wisconsin
Milwaukee, Wisconsin
Chapter 14: Gastrointestinal System
Barbara Leeper, MN, RN-BC, CNS-MS, CCRN, FAHA
Clinical Nurse Specialist
Cardiovascular Services
Baylor University Medical Center
Dallas, Texas
Chapter 9: Cardiovascular System
Chapter 19: Advanced Cardiovascular Concepts
Dea Mahanes, RN, MSN, CCRN, CNRN, CCNS
Advanced Practice Nurse 3
Clinical Nurse Specialist
Nerancy Neuro ICU
University of Virginia Health System
Charlottesville, Virginia
Chapter 12: Neurologic System
Chapter 20: Advanced Neurologic Concepts
Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC,
CEN, CNRN, CMSRN, NP
Instructor
Western Kentucky University
Bowling Green, Kentucky
Chapter 4: Interpretation and Management of Basic
�Cardiac Rhythms
Carol Rees Parrish, MS, RD
Nutrition Support Specialist
Digestive Health Center of Excellence
Department of Nutrition Services
University of Virginia Health System
Charlottesvillle, Virginia
Chapter 14: Gastrointestinal System
Maureen A. Seckel, APN, ACNS, BC, CCNS, CCRN
Clinical Nurse Specialist Medical Pulmonary Critical Care
Christiana Care Health System
Newark, Delaware
Chapter 5: Airway and Ventilatory Management
Chapter 10: Respiratory System
Mary Fran Tracy, PhD, RN, CCNS, FAAN
Critical Care Clinical Nurse Specialist
University of Minnesota Medical Center, Fairview
Minneapolis, Minnesota
Chapter 1: Assessment of Progressive Care Patients and
Their Families
Chapter 2: Planning Care for Progressive Care Patients and
Their Families
Allen C. Wolfe, Jr., MSN, RN, CFRN, CCRN, CMTE
Clinical Education Director/Clinical Specialist
Air Methods Corporation
Community Based Services
Denver, Colorado
Chapter 17: Trauma
 Reviewers

John M. Allen, PharmD, BCPS Beth Epstein, PhD, RN

Assistant Clinical Professor Associate Professor
Auburn University University of Virginia School of Nursing
Harrison School of Pharmacy Faculty Affiliate University of Virginia Center for Biomedi-
Mobile, Alabama cal Ethics and Humanities
University of Virginia
Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, FAAN
Charlottesville, Virginia
Advanced Practice Nurse; Clinical Faculty
La Salle University John J. Gallagher, MSN, RN, CCNS, CCRN, RRT
Holy Family University Trauma Program Manager
Philadelphia, Pennsylvania Division of Traumatology, Surgical Critical Care and Emer-
gency Surgery
Cheri S. Blevins, MSN RN CCRN CCNS
Hospital of the University of Pennsylvania
APN-2 Clinical Nurse Specialist
Philadelphia, Pennsylvania
Medical ICU
University of Virginia Health System Tonja Hartjes, DNP, ACNP/FNP-BC, CCRN-CSC
Charlottesville, Virginia Associate Clinical Professor
University of Florida, College of Nursing
Shawn Cosper, MSN, RN
Adult Gerontology and Acute Care ARNP Program and
Education Consultant-Critical Care
Cardiothoracic Surgery ARNP Shands UF
Education Department
Gainesville, Florida
Brookwood Medical Center
Birmingham, Alabama Barbara S. Jacobs, MSN, RN-BC, CCRN, CENP
Senior Director/Chief Nurse Officer
Sarah Jane White Craig, MSN, RN, CCNS, CCRN
Suburban Hospital/Johns Hopkins Medicine
Clinical Nurse Specialist
Bethesda, Maryland
Postoperative Thoracic-Cardiovascular Surgery Service
University of Virginia Health System Katherine Johnson, MS, CNRN
Charlottesville, Virginia Neuro CNS
Queens Medical Center
Tina Cronin, APRN, CCNS, CCRN, CNRN
Honolulu, Hawaii
Director Nursing Education, Practice
Novant Health Greater Charlotte Market Victoria A. Kark, RN, MSN, CCRN,CCNS, CSC
Charlotte, North Carolina Clinical Nurse Specialist
Surgical Intensive Care Unit
Linda DeStefano, CNS, NP, FCCM
Walter Reed National Military Medical Center
Clinical Nurse Specialist, Critical Care Services
Bethesda, Maryland
Saddleback Memorial Medical Center
Laguna Hills, California

xix
xx REVIEWERS

Deborah Klein, MSN, RN, ACNS-BC, CCRN, CHFN, Michelle A. Weber, RN, MSN, ACNP-BC
FAHA Nurse Practitioner
Clinical Nurse Specialist Coronary ICU, Heart Failure ICU, Division of General Surgery
and Cardiac Short Stay/PACU Medical College of Wisconsin
Cleveland Clinic Milwaukee, Wisconsin
Cleveland, Ohio
Brian Widmar, PhD, RN, ACNP-BC, CCRN
Julie Painter, RN, MSN, OCN Assistant Professor of Nursing
Community Health Network Vanderbilt University School of Nursing
Oncology Clinical Nurse Specialist Nashville, Tennessee
Indianapolis, Indiana
Susan L. Woods, PhD, RN, FAAN
Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN, CEN Professor Emerita
Independent Clinical Nurse Specialist and Education Department of Biobehavioral Nursing and Health Systems
­Consultant School of Nursing
Kill Devil Hills, North Carolina University of Washington
Seattle, Washington
Christine Schulman, MS, RN, CNS, CCRN
Critical Care CNS Amanda Zomp, PharmD, BCPS
Legacy Health Critical Care Clinical Pharmacist
Portland, Oregon University of Virginia Medical Center
Charlottesville, Virginia
Michelle VanDemark, MSN, RN, ANP-BC, CNRN, CCSN
Neurocritical Care Nurse Practitioner
Sanford Medical Center
Sioux Falls, South Dakota
 Preface
Progressive care nursing is a complex, challenging area of
nursing practice, where clinical expertise is developed over
time by integrating progressive care knowledge, clinical
skills, and caring practices. This textbook, the first to spe-
cifically address the educational needs of the new progressive
care practitioner, succinctly presents essential information
about how best to safely and competently care for acutely ill
patients and their families.
As it has since the first edition, the American Associa-
tion of Critical-Care Nurses reaffirms this book’s value to the
AACN community and especially to clinicians at the point
of care. The title continues to carry AACN’s name, as it has
since the first edition.
AACN Essentials of Progressive Care Nursing provides
essential information on the care of adult acutely ill patients
and families. The book recognizes the learner’s need to
assimilate foundational knowledge before attempting to
master more complex progressive care nursing concepts.
Written by nationally acknowledged clinical experts in criti-
cal and acute care nursing, this textbook sets the standard for
progressive care nursing education.
AACN Essentials of Progressive Care Nursing:
• Succinctly presents essential information for the safe
and competent care of progressive care patients and
their families, building on the clinician’s significant
medical-surgical nursing knowledge base, avoiding
repetition of previously acquired information
• Stages the introduction of advanced concepts in pro-
gressive care nursing after essential concepts have
been mastered
• Provides clinicians with clinically relevant tools and
guides to use as they care for progressive care patients
and families
The AACN Essentials of Progressive Care Nursing is divided
into four parts:
• Part I: The Essentials presents essential information
that clinicians must understand to provide safe, com-
petent nursing care to the majority of progressive
care patients, regardless of their underlying medical
diagnoses. This part includes content on essential
concepts of assessment, diagnosis, planning, and
interventions common to progressive care patients
and families; interpretation and management of
�cardiac rhythms; hemodynamic monitoring; air-
way and ventilatory management; pain and sedation
�management; pharmacology; and ethical and legal
considerations. Chapters in Part I present content in
enough depth to ensure that essential information
is available for the new progressive care clinician to
develop competence, while sequencing pathological
conditions in Part II and advanced content in a later
part of the book (Part III).
• Part II: Pathologic Conditions covers pathologic
conditions and management strategies commonly
encountered in progressive care, closely paralleling
the blueprint for the PCCN certification examination.
Chapters in this part are organized by body systems
and selected progressive care conditions (cardiovas-
cular, respiratory, multisystem, neurologic, hemato-
logic and immune, gastrointestinal, renal, endocrine,
and trauma).
• Part III: Advanced Concepts in Caring for the Progres-
sive Care Patient presents advanced progressive care
concepts or pathologic conditions that are more com-
plex and represent expert level information. Specific
advanced chapter content includes ECG concepts,
cardiovascular concepts, and neurologic concepts.
• Part IV: Key Reference Information contains reference
information that clinicians will find helpful in the
clinical area (normal laboratory and diagnostic val-
ues; algorithms for advanced cardiac life support; and
summary tables of progressive care drugs and cardiac
rhythms). Content is presented primarily in table for-
mat for quick reference.
Each chapter in Part I, II, and III, begins with “Knowledge
Competencies” that can be used to guide informal or formal
teaching and to gauge the learner’s progress. In addition,
xxi
xxii PREFACE

each of the chapters provide “Essential Content Case” stud-
ies that focus on key information presented in the chapters
in order to assist clinicians in understanding the chapter con-
tent and how to best assess and manage conditions and prob-
lems encountered in progressive care. The case studies also
are designed to enhance the learners understanding of the
magnitude of the pathologic problems/conditions and their
impact on patients and families. Questions and answers are
provided for each case so the learner may test his/her knowl-
edge of the essential content.
I believe that there is no greater way to protect our
patients than to ensure that an educated clinician cares for
them. Safe passage in progressive care is ensured by compe-
tent, skilled, knowledgeable, and caring clinicians. I sincerely
believe that this textbook will help you make it so!
Suzi Burns
The Essentials I
This page intentionally left blank
 Assessment of
Progressive Care Patients
and Their Families
KNOWLEDGE COMPETENCIES
1.╇Discuss the importance of a consistent and
systematic approach to assessment of progressive
care patients and their families.
2.╇Identify the assessment priorities for different
stages of an acute illness:
•â•‡ Prearrival assessment
•â•‡ Arrival quick check
The assessment of acutely ill patients and their families is
an essential competency for progressive care practitioners.
Information obtained from an assessment identifies the
immediate and future needs of the patient and family so
a plan of care can be initiated to address or resolve these
needs.
Traditional approaches to patient assessment include a
complete evaluation of the patient’s history and a comprehen-
sive physical examination of all body systems. This approach
is ideal, though progressive care clinicians must balance
the need to gather data while simultaneously prioritizing
and providing care to acutely ill patients who may either be
improving or decompensating. Traditional approaches and
techniques for assessment must be modified in progressive
care to balance the need for information, while considering
the acute nature of the patient and family’s situation.
This chapter outlines an assessment approach that rec-
ognizes the dynamic nature of an acute illness. This approach
emphasizes the collection of assessment data in a phased or
staged manner consistent with patient care priorities. The
components of the assessment can be used as a generic tem-
plate for assessing most progressive care patients and fami-
lies. The assessment can then be individualized by adding
more specific assessment requirements depending on the
Mary Fran Tracy
1
•â•‡ Comprehensive initial assessment
•â•‡ Ongoing assessment
3.╇Describe how the assessment is altered based on
the patient’s clinical status.
specific patient diagnosis. These specific components of the
assessment are identified in subsequent chapters.
Crucial to developing competence in assessing pro-
gressive care patients and their families is a consistent and
systematic approach to assessments. Without this approach,
it would be easy to miss subtle signs or details that may
identify an actual or potential problem and also indicate a
patient’s changing status. Assessments should focus first on
the patient, then on the technology. The patient needs to be
the focal point of the progressive care practitioner’s attention,
with technology augmenting the information obtained from
the direct assessment.
There are two standard approaches to assessing
patients—the head-to-toe approach and the body systems
approach. Most progressive care nurses use a combination—
a systems approach applied in a top-to-bottom manner. The
admission and ongoing assessment sections of this chapter
are presented with this combined approach in mind.
ASSESSMENT FRAMEWORK
Assessing the progressive care patient and family begins from
the moment the nurse is made aware of the pending admission
or transfer of the patient and continues until transitioning to
3
4 CHAPTER 1. Assessment of Progressive Care Patients and Their Families
the next phase of care. The assessment process can be viewed
as four distinct stages: (1) prearrival, (2) arrival quick check
(“just the basics”), (3) comprehensive initial assessment, and
(4) ongoing assessment.
Prearrival Assessment
Patients admitted to a progressive care unit may be transi-
tioning from a more intensive level of care, as they become
more stable and improve in condition. Conversely, they may
be transferred from a lower level of care, as their physiologic
status may be deteriorating. In either case, the progressive
care patient has the potential to have a rapid change in status.
A prearrival assessment begins the moment the information
is received about the upcoming admission of the patient to
the progressive care unit. This notification comes from the
initial healthcare team contact. The contact may be a transfer
from another facility or a transfer from other areas within the
hospital such as the emergency room, operating room, the
intensive care unit (ICU), or medical/surgical nursing unit.
The prearrival assessment paints the initial picture of the
patient and allows the progressive care nurse to begin antici-
pating the patient’s physiologic and psychological needs. This
assessment also allows the progressive care nurse to deter-
mine the appropriate resources that are needed to care for
the patient. The information received in the prearrival phase
is crucial because it allows the progressive care nurse to
adequately prepare the environment to meet the specialized
needs of the patient and family.
Arrival Quick Check
An arrival quick check assessment is obtained immediately
upon arrival and is based on assessing the parameters rep-
resented by the ABCDE acronym (Table 1-1). The arrival
quick check assessment is a quick overview of the adequacy
of ventilation and perfusion to ensure early intervention for
any life-threatening situations. The arrival quick check is a
high-level view of the patient, but is essential because it vali-
dates that basic cardiac and respiratory function is sufficient,
and can be used as a baseline for potential future changes in
a condition.
Comprehensive Initial Assessment
A comprehensive assessment is performed as soon as pos-
sible, with the timing dictated by the degree of physiologic
stability and emergent treatment needs of the patient. If the
patient is being admitted directly to the progressive care unit
from outside the hospital, the comprehensive assessment is
TABLE 1-1. ABCDE ACRONYM
Airway
Breathing
Circulation, Cerebral perfusion, and Chief complaint
Drugs and Diagnostic tests
Equipment
an in-depth assessment of the past medical and social history
and a complete physical examination of each body system. If
the patient is being transferred to the progressive care unit
from another area in the hospital, the comprehensive assess-
ment includes a review of the admission assessment data and
comparison to the current assessment of the patient. The
comprehensive assessment is vital to successful outcomes
because it provides the nurse invaluable insight into proac-
tive interventions that may be needed.
Ongoing Assessment
After the baseline comprehensive assessment is completed,
ongoing assessments—an abbreviated version of the com-
prehensive assessment—are performed at varying intervals.
The assessment parameters outlined in this section are usu-
ally completed for all patients, in addition to other ongoing
assessment requirements related to the patient’s specific con-
dition, treatments, and response to therapy.
Patient Safety Considerations in Admission Assessments
Admission of an acutely ill patient can be a chaotic event
with multiple disciplines involved in many activities. It is at
this time, however, that health-care providers must be par-
ticularly cognizant of accurate assessments and data gather-
ing to ensure the patient is cared for safely with appropriate
interventions. Obtaining inaccurate information on admis-
sion can lead to ongoing errors that may not be easily recti-
fied or discovered and lead to poor patient outcomes.
Obtaining information from an acutely ill patient may
be difficult, if possible at all. If the patient is unable to sup-
ply information, other sources must be utilized such as fam-
ily members, electronic health records (EHRs), past medical
records, transport records, or information from the patient’s
belongings. Of particular importance at admission is obtain-
ing accurate patient identification, as well as past medical
history including any known allergies. Current medication
regimens are extremely helpful if feasible, as they can provide
clues to the patient’s medical condition and perhaps contrib-
uting factors to the current condition.
With the increasing use of EHRs, there are improving
opportunities for timely access to past and current medical
history information of patients. Healthcare providers may
have access to both inpatient and outpatient records within
the same healthcare system, assisting them to quickly iden-
tify the patient’s most recent medication regimen and labo-
ratory and diagnostic results. In addition, many healthcare
systems within the same geographic locations are work-
ing together to make available intersystem access to medi-
cal records of patients being treated at multiple healthcare
institutions. This is particularly beneficial when patients are
unable to articulate imperative medical information includ-
ing advance directives, allergies, and next of kin.
Careful physical assessment on admission to the pro-
gressive care unit is pivotal for providing prevention and/or
early treatment for complications associated with the illness.
 ARRIVAL QUICK CHECK ASSESSMENT  5

Of particular importance is the assessment of risk for pressure TABLE 1-3. EQUIPMENT FOR STANDARD ROOM SETUP
ulcer formation, alteration in mental status, and/or falls. Risks • Bedside ECG or telemetry monitoring and invasive pressure monitor with
associated with accurate patient identification never lessen, appropriate cables
particularly as these relate to interventions such as perform- • ECG electrodes
• Blood pressure cuff
ing invasive procedures, medication administration, blood
• Pulse oximetry
administration, and obtaining laboratory tests. Nurses need • Suction gauges and canister setup
to be cognizant of safety issues as treatment begins as well; for • Suction catheters
example, accurate programming of pumps infusing high-risk • Bag valve mask device
medications is essential. It is imperative that nurses use all • Oxygen flow meter, appropriate tubing, and appropriate oxygen
delivery device
safety equipment available to them such as pre-programmed
• IV poles and infusion pumps
drug libraries in infusion pumps and bar coding technology. • Bedside supply cart that contains such things as alcohol swabs, nonsterile
Healthcare providers must also ensure the safety of invasive gloves, syringes, chux, and dressing supplies
procedures that may be performed emergently. • Admission kit that usually contains bath basin and general hygiene
supplies (if direct admission)
• Admission and progressive care paper and/or electronic documentation
PREARRIVAL ASSESSMENT: BEFORE THE ACTION BEGINS forms

A prearrival assessment begins when information is received

about the pending arrival of the patient. The prearrival
report, although abbreviated, provides key information ongoing treatments, and pending or completed laboratory or
about the chief complaint, diagnosis, or reason for admis- diagnostic tests. It is also important to consider the potential
sion, pertinent history details, and physiologic stability of isolation requirements for the patient (eg, neutropenic pre-
the patient (Table 1-2). It also contains the gender and age cautions or special respiratory isolation). Being prepared for
of the patient and information on the presence of invasive isolation needs prevents potentially serious exposures to the
tubes and lines, medications being administered, other patient, roommates, or the healthcare providers. This infor-
mation assists the clinician in anticipating the patient’s physi-
ologic and emotional needs prior to admission or transfer
TABLE 1-2. SUMMARY OF PREARRIVAL AND ARRIVAL QUICK and in ensuring that the bedside environment is set up to
CHECK ASSESSMENTS provide all monitoring, supply, and equipment needs prior
Prearrival Assessment
to the patient’s arrival.
• Abbreviated report on patient (age, gender, chief complaint, diagnosis, Many progressive care units have a standard room setup,
allergies pertinent history, physiologic status, invasive devices, equipment, guided by the major diagnosis-related groups of patients
and status of laboratory/diagnostic tests) each unit receives. The standard monitoring and equipment
• Complete room setup, including verification of proper equipment functioning list for each unit varies; however, there are certain common
Admission Quick Check Assessment requirements (Table 1-3). The standard room setup is modi-
• General appearance (consciousness)
• Airway:
fied for each admission to accommodate patient-specific
Patency needs (eg, additional equipment, intravenous [IV] fluids,
Position of artificial airway (if present) such as tracheostomy medications). Proper functioning of all bedside equipment
• Breathing: should be verified prior to the patient’s arrival.
Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, It is also important to prepare the medical records forms,
use of accessory muscles)
Breath sounds
which usually consist of paper flow sheets or computerized data
Presence of spontaneous breathing entry system to record vital signs, intake and output, medica-
• Circulation and Cerebral Perfusion: tion administration, patient care activities, and patient assess-
ECG (rate, rhythm, and presence of ectopy) ment. The prearrival report may suggest pending procedures,
Blood pressure necessitating the organization of appropriate supplies at the
Peripheral pulses and capillary refill
Skin color, temperature, moisture
bedside. Having the room prepared and all equipment available
Presence of bleeding facilitates a rapid, smooth, and safe admission of the patient.
Level of consciousness, responsiveness
• Chief Complaint:
Primary body system
ARRIVAL QUICK CHECK ASSESSMENT
Associated symptoms From the moment the patient arrives in the progressive care
• Drugs and Diagnostic Tests:
unit setting, his or her general appearance is immediately
Drugs prior to admission (prescribed, over-the-counter, illicit)
Current medications observed and assessment of ABCDEs is quickly performed
Review diagnostic test results (see Table 1-1). The seriousness of the problem(s) is deter-
• Equipment: mined so any urgent needs can be addressed first. The patient
Patency of vascular and drainage systems is connected to the appropriate monitoring and support
Appropriate functioning and labeling of all equipment connected to patient
equipment, medications being administered are verified,
6 CHAPTER 1. Assessment of Progressive Care Patients and Their Families
Essential Content Case
Prearrival Assessment
The charge nurse notifies Sue that she will be receiving
a 26-year-old man from the ICU who was involved in a
serious car accident 14 days ago. The ICU nurse caring for
the patient has called to give Sue a report following the
hospital’s standardized report format.
Case Question 1: What basic information will Sue want
to know from the pre-arrival communication with the
ICU nurse?
Case Question 2: What patient issues are likely to need
immediate assessment and/or intervention on arrival to
the progressive care unit in order to ensure the appropri-
ate equipment is set up in the room?
Case Question 3: What information should be included
in the more formal handoff between the ICU nurse and
Sue after the patient is settled in his room in the Progres-
sive Care Unit?
Answers
1. Patient name/age, type and date of accident, extent
of accident injuries, pertinent medical history, aller-
gies, vital signs and significant assessment information,
placement of lines and tubes, medications being admin-
istered, significant laboratory results, anticipated plan
for care and discharge plan, presence of family, and any
other special instructions.
The patient suffered a closed head injury and chest
trauma with collapsed left lung. The patient had been
intubated and placed on a mechanical ventilator. The
patient had developed pneumonia when in the ICU and
though he now exhibited stable oxygenation, a trache-
ostomy was required to manage copious secretions. He
had now been weaned off the ventilator and was requir-
ing 30% Fio2. A central line with a central venous pres-
sure (CVP) setup and a left chest tube to water seal were
in place. Sue questions the critical care nurse regarding
whether the patient has been agitated, his level of con-
sciousness (LOC) and neuro deficits, if a Foley catheter
or nasogastric tube is present, and whether the family has
been notified of the transfer to the progressive care unit.
2. V ital signs, neurologic status, the tracheostomy and
oxygen requirements of the patient, medications are
appropriately infusing and whether the patient is agi-
tated or experiencing extensive pain.
Sue goes to check the patient’s room prior to admis-
sion and begins to do a mental check of what will be needed.
“The patient has a tracheostomy so I’ll connect the AMBU
bag to the oxygen source, check for suction catheters, and
make sure the suction systems are working. The pulse oxim-
etry is ready to use. I’ll also ensure the telemetry pack has
fully charged batteries and have the ECG electrodes ready
to apply. The CVP line flush system and transducer are also
ready to be connected. The IV infusion devices are set up.
This patient has an altered LOC, which means frequent
neuro checks. I have my pen light handy. The computer in
the room is on and ready for me to begin documentation.
I think I’m ready.”
3. Using an SBAR format, the ICU nurse can give more
detailed information about the injuries from the car
accident, the patient’s complete medical history as
known, reiteration of known allergies, a system by sys-
tem assessment review, significant diagnostic test results,
confirmation of all invasive lines and equipment settings,
the anticipated plan for ongoing assessments, interven-
tions, and discharge planning, and any pertinent family
information. Sue should also have an opportunity to ask
any clarifying questions she might have.
and essential laboratory and diagnostic tests are ordered.
Simultaneously with the ABCDE assessment, the patient’s
nurse must validate that the patient is appropriately identified
through a hospital wristband, personal identification, or fam-
ily identification. In addition, the patient’s allergy status is veri-
fied, including the type of reaction that occurs and what, if any,
treatment is used to alleviate the allergic response.
There may be other healthcare professionals present
to receive the patient and assist with arrival tasks. The pro-
gressive care nurse, however, is the leader of the receiving
team. While assuming the primary responsibility for assess-
ing the ABCDEs, the progressive care nurse directs the team
in completing delegated tasks, such as changing over to the
unit equipment or attaching monitoring cables. Without a
leader of the receiving team, care can be fragmented and vital
assessment clues overlooked.
The progressive care nurse rapidly assesses the ABCDEs
in the sequence outlined in this section. If any aspect of this
preliminary assessment deviates from normal, interventions
are immediately initiated to address the problem before con-
tinuing with the arrival quick check assessment. Addition-
ally, regardless of whether the patient appears to be conscious
or not, it is important to talk to him or her throughout this
admission process regarding what is occurring with each
interaction and intervention.
Airway and Breathing
Patency of the patient’s airway is verified by having the
patient speak, watching the patient’s chest rise or fall, or
both. If the airway is compromised, verify that the head has
been positioned properly to prevent the tongue from occlud-
ing the airway. Inspect the upper airway for the presence of
blood, vomitus, and foreign objects before inserting an oral
airway if one is needed. If the patient already has an artificial
airway, such as a cricothyrotomy or tracheostomy, ensure
that the airway is secured properly. Note the position of the
tracheostomy and size marking to assist future comparisons
for proper placement. Suctioning of the upper airway, either
through the oral cavity or artificial airway, may be required
to ensure that the airway is free from secretions. Note the
amount, color, and consistency of secretions removed.
Note the rate, depth, pattern, and symmetry of breath-
ing; the effort it is taking to breathe; the use of accessory
muscles; and, if mechanically ventilated, whether breathing

is in synchrony with the ventilator. Observe for nonverbal
signs of respiratory distress such as restlessness, anxiety, or
change in mental status. Auscultate the chest for presence of
bilateral breath sounds, quality of breath sounds, and bilat-
eral chest expansion. Optimally, both anterior and posterior
breath sounds are auscultated, but during this arrival quick
check assessment, time generally dictates that just the ante-
rior chest is assessed. If noninvasive oxygen saturation moni-
toring is available, observe and quickly analyze the values.
If chest tubes are present, note whether they are pleural
or mediastinal chest tubes. Ensure that they are connected
to suction, if appropriate, and are not clamped or kinked.
Assess whether they are functioning properly (eg, airleak,
fluid fluctuation with respirations) and the amount and char-
acter of the drainage.
Circulation and Cerebral Perfusion
Assess circulation by quickly palpating a pulse and view-
ing the electrocardiogram (ECG) and monitor for the heart
rate, rhythm, and presence of ectopy if ECG monitoring is
ordered. Obtain blood pressure and temperature. Assess
peripheral perfusion by evaluating the color, temperature,
and moisture of the skin along with capillary refill. Based on
the prearrival report and reason for admission, there may be
a need to inspect the body for any signs of blood loss and
determine if active bleeding is occurring.
Evaluating cerebral perfusion in the arrival quick check
assessment is focused on determining the functional integ-
rity of the brain as a whole, which is done by rapidly evaluat-
ing the gross LOC. Evaluate whether the patient is alert and
aware of his or her surroundings, whether it takes a verbal or
painful stimulus to obtain a response, or whether the patient
is unresponsive. Observing the response of the patient dur-
ing movement from the stretcher to the progressive care unit
bed can supply additional information about the LOC. Note
whether the patient’s eyes are open and watching the events
around him or her; for example, does the patient follow sim-
ple commands such as “Place your hands on your chest” or
“Slide your hips over”? If the patient is unable to talk because
of trauma or the presence of an artificial airway, note whether
his or her head nods appropriately to questions.
Chief Complaint
Optimally, the description of the chief complaint is obtained
from the patient, but this may not be realistic. The patient
may be unable to respond or may not speak English. Data
may need to be gathered from family, friends, or bystanders,
or from the completed admission database if the patient has
been transferred from another area in the hospital. If the
patient or family cannot speak English, an approved hospi-
tal translator should be contacted to help with the interview
and subsequent evaluations and communication. It is not
advised to use family or friends to translate for a non-Eng-
lish speaking patient for reasons such as protection of the
ARRIVAL QUICK CHECK ASSESSMENT  7
patient’s privacy, the likelihood that family will not under-
stand appropriate medical terminology for translation, and
to avoid well-intentioned but potential bias in translating
back and forth for the patient.
In the absence of a history source, practitioners must
depend exclusively on the physical findings (eg, presence of
medication patches, permanent pacemaker, or old surgery
scars), knowledge of pathophysiology, and access to prior
paper or electronic medical records to identify the potential
causes of the admission.
Assessment of the chief complaint focuses on determin-
ing the body systems involved and the extent of associated
symptoms. Additional questions explore the time of onset,
precipitating factors, and severity. Although the arrival quick
check phase is focused on obtaining a quick overview of the
key life-sustaining systems, a more in-depth assessment of a
particular system may need to be done at this time; for exam-
ple, in the prearrival case study scenario presented, comple-
tion of the ABCDEs is followed quickly by more extensive
assessment of both the nervous and respiratory systems.
Drugs and Diagnostic Tests
Information about infusing medications and diagnostic tests
is integrated into the priority of the arrival quick check. If
IV access is not already present, it should be immediately
obtained and intake and output records started. If IV medi-
cations are presently being infused, check the drug(s) and
verify the correct infusion of the desired dosage and rate.
Determine the latest results of any diagnostic tests
already performed. Augment basic screening tests (Table 1-4)
with additional tests appropriate to the underlying diagnosis,
chief complaint, transfer status, and recent procedures. Review
any available laboratory or diagnostic data for abnormalities
or indications of potential problems that may develop. The
abnormal laboratory and diagnostic data for specific patho-
logic conditions will be covered in subsequent chapters.
Equipment
Quickly evaluate all vascular and drainage tubes for location
and patency, and connect them to appropriate monitoring
or suction devices. Note the amount, color, consistency, and
odor of drainage secretions. Verify the appropriate func-
tioning of all equipment attached to the patient and label as
required. While connecting the monitoring and care equip-
ment, it is important for the nurse to continue assessing the
patient’s respiratory and cardiovascular status until it is clear
TABLE 1-4. COMMON DIAGNOSTIC TESTS OBTAINED DURING ARRIVAL QUICK
CHECK ASSESSMENT
Serum electrolytes
Glucose
Complete blood count with platelets
Coagulation studies
Chest x-ray
ECG
8 CHAPTER 1. Assessment of Progressive Care Patients and Their Families

that all equipment are functioning appropriately and can be The comprehensive assessment also defines the patient’s pre-
relied on to transmit accurate patient data. event health status, determining problems or limitations that
The arrival quick check assessment is accomplished in may impact patient status during this admission as well as
a matter of a few minutes. After completion of the ABCDEs potential issues for future transitioning of care. The content
assessment, the comprehensive assessment begins. If at any presented in this section is a template to screen for abnor-
phase during the arrival quick check a component of the malities or determine the extent of injury or disease. Any
ABCDEs has not been stabilized and controlled, energy is abnormal findings or changes from baseline warrant a more
focused first on resolving the abnormality before proceeding in-depth evaluation of the pertinent system.
to the comprehensive admission assessment. The comprehensive assessment includes the patient’s
After the arrival, quick check assessment is complete, medical and brief social history, and physical examination
and if the patient requires no urgent intervention, there may of each body system. The comprehensive assessment of the
now be time for a more thorough report from the healthcare progressive care patient is similar to admission assessments
providers transferring the patient to the progressive care for medical-surgical patients. This section describes only
unit. It is important to note that handoffs with transitions those aspects of the assessment that are unique to progressive
of care are possible intervals when safety gaps may occur. care patients or require more extensive information than is
Omission of pertinent information or miscommunication obtained from a medical-surgical patient. The entire assess-
at this critical juncture can result in patient care errors. Use ment process is summarized in Tables 1-6 and 1-7.
of a standardized handoff format—such as the “SBAR” for- Changing demographics of progressive care units indi-
mat which includes communication of the Situation, Back- cate that an increasing proportion of patients are elderly,
ground, Assessment, and Recommendations—can minimize
the potential for miscommunication. Use the handoff as an
opportunity to confirm your observations such as dosage of TABLE 1-6. SUMMARY OF COMPREHENSIVE INITIAL
ASSESSMENT REQUIREMENTS
infusing medications, abnormalities found on the quick check
assessment, and any potential inconsistencies noted between Past Medical History
• Medical conditions, surgical procedures
your assessment and the prearrival report. It is easier to clarify
• Psychiatric/emotional problems
questions while the transporters are still present, if possible. • Hospitalizations
This may also be an opportunity for introductory inter- • Medications (prescription, over-the-counter, illicit drugs) and time of last
actions with family members or friends, if present. Introduce medication dose
yourself, offer reassurance, and confirm the intention to give • Allergies
• Review of body systems (see Table 1-7)
the patient the best care possible (Table 1-5). If feasible, allow
Social History
them to stay with the patient in the room during the arrival
• Age, gender
process. If this is not possible, give them an approximate • Ethnic origin
time frame when they can expect to receive an update from • Height, weight
you on the patient’s condition. Have another member of the • Highest educational level completed
healthcare team escort them to the appropriate waiting area. • Occupation
• Marital status
• Primary family members/significant others/decision makers
• Religious affiliation
COMPREHENSIVE INITIAL ASSESSMENT • Advance Directive and Durable Power of Attorney for Health Care
Comprehensive assessments determine the physiologic and • Substance use (alcohol, drugs, caffeine, tobacco)
• Domestic Abuse or Vulnerable Adult Screen
psychosocial baseline so that future changes can be compared
Psychosocial Assessment
to determine whether the status is improving or deteriorating. • General communication
• Coping styles
• Anxiety and stress
TABLE 1-5. EVIDENCE-BASED PRACTICE: FAMILY NEEDS ASSESSMENT • Expectations of progressive care unit
Quick Assessment • Current stresses
• Offer realistic hope • Family needs
• Give honest answers and information Spirituality
• Give reassurance • Faith/spiritual preference
Comprehensive Assessment • Healing practices
• Use open-ended communication and assess their communication style Physical Assessment
• Assess family members’ level of anxiety • Nervous system
• Assess perceptions of the situation (knowledge, comprehension, expecta- • Cardiovascular system
tions of staff, expected outcome) • Respiratory system
• Assess family roles and dynamics (cultural and religious practices, values, • Renal system
spokesperson) • Gastrointestinal system
• Assess coping mechanisms and resources (what do they use, social net- • Endocrine, hematologic, and immune systems
work and support) • Integumentary system

TABLE 1-7. SUGGESTED QUESTIONS FOR REVIEW OF PAST HISTORY CATEGORIZED
BY BODY SYSTEM
Body System History Questions
Nervous • Have you ever had a seizure?
• Have you ever fainted, blacked out, or had delirium
tremens (DTs)?
• Do you ever have numbness, tingling, or weakness in
any part of your body?
• Do you have any difficulty with your hearing, vision, or
speech?
• Has your daily activity level changed due to your
present condition?
• Do you require any assistive devices such as canes?
Cardiovascular • Have you experienced any heart problems or disease
such as heart attacks or strokes?
• Do you have any problems with extreme fatigue?
• Do you have an irregular heart rhythm?
• Do you have high blood pressure?
• Do you have a pacemaker or an implanted defibrillator?
Respiratory • Do you ever experience shortness of breath?
• Do you have any pain associated with breathing?
• Do you have a persistent cough? Is it productive?
• Have you had any exposure to environmental agents
that might affect the lungs?
• Do you have sleep apnea?
Renal • Have you had any change in frequency of urination?
• Do you have any burning, pain, discharge, or difficulty
when you urinate?
• Have you had blood in your urine?
Gastrointestinal • Has there been any recent weight loss or gain?
• Have you had any change in appetite?
• Do you have any problems with nausea or vomiting?
• How often do you have a bowel movement and has
there been a change in the normal pattern? Do you
have blood in your stools?
• Do you have dentures?
• Do you have any food allergies?
Integumentary • Do you have any problems with your skin?
Endocrine • Do you have any problems with bleeding?
Hematologic • Do you have problems with chronic infections?
Immunologic • Have you recently been exposed to a contagious illness?
Psychosocial • Do you have any physical conditions, which make com-
munication difficult (hearing loss, visual disturbances,
language barriers, etc)?
• How do you best learn? Do you need information
repeated several times and/or require information in
advance of teaching sessions?
• What are the ways you cope with stress, crises, or pain?
• Who are the important people in your family or network?
• Who do you want to make decisions with you, or for you?
• Have you had any previous experiences with acute illness?
• Have you ever been abused?
• Have you ever experienced trouble with anxiety,
irritability, being confused, mood swings, or suicidal
attempts?
• What are the cultural practices, religious influences, and
values that are important to you or your family?
• What are family members’ perceptions and expectations
of the progressive care staff and the setting?
Spiritual • What is your faith or spiritual preference?
• What practices help you heal or deal with stress?
• Would you like to see a chaplain, priest, or other
spiritual guide?
COMPREHENSIVE INITIAL ASSESSMENT  9
requiring assessments to incorporate the effects of aging.
Although assessment of the aging adult does not differ sig-
nificantly from the younger adult, understanding how aging
alters the physiologic and psychological status of the patient
is important. Key physiologic changes pertinent to the pro-
gressive care elderly adult are summarized in Table 1-8.
Additional emphasis must also be placed on the past medi-
cal history because the aging adult frequently has multiple
coexisting illnesses and is taking several prescriptive and
over-the-counter medications. Social history must address
issues related to home environment, support systems, and
self-care abilities. The interpretation of clinical findings in
the elderly must also take into consideration the fact that the
coexistence of several disease processes and the diminished
reserves of most body systems often result in more rapid
physiologic deterioration than in younger adults.
Past Medical History
If the patient is being directly admitted to the progressive
care unit, it is important to determine prior medical and sur-
gical conditions, hospitalization, medications, and symptoms
besides the primary event that brought the patient to the
hospital (see Table 1-7). In reviewing medication use, ensure
assessment of over-the-counter medication use as well as
any herbal or alternative supplements. For every positive
symptom response, additional questions should be asked to
explore the characteristics of that symptom (Table 1-9). If the
patient is a transfer from another area in the hospital, review
the admission assessment information, and clarify as needed
with the patient and family. Be aware of opportunities for
health teaching and transition planning needs for discharge
to home or to a rehabilitation facility.
Social History
Inquire about the use and abuse of caffeine, alcohol, tobacco,
and other substances. Because the use of these agents can
have major implications for the progressive care patient,
questions are aimed at determining the frequency, amount,
and duration of use. Honest information regarding alcohol
and substance abuse, however, may not be always forth-
coming. Alcohol use is common in all age groups. Phrasing
questions about alcohol use by acknowledging this fact may
be helpful in obtaining an accurate answer (eg, “How much
alcohol do you drink?” vs “Do you drink alcohol and how
much?”). Family or friends might provide additional infor-
mation that might assist in assessing these parameters. The
information revealed during the social history can often be
verified during the physical assessment through the presence
of signs such as needle track marks, nicotine stains on teeth
and fingers, or the smell of alcohol on the breath.
Patients should also be asked about physical and emo-
tional safety in their home environment in order to uncover
potential domestic or elder abuse. It is best if patients can
be assessed for vulnerability when they are alone to prevent
placing them in a position of answering in front of family
10 CHAPTER 1. Assessment of Progressive Care Patients and Their Families

TABLE 1-8. PHYSIOLOGIC EFFECTS OF AGING

Body System Effects

Nervous Diminished hearing and vision, short-term memory loss, altered motor coordination, decreased muscle tone and strength, slower
response to verbal and motor stimuli, decreased ability to synthesize new information, increased sensitivity to altered temperature
states, increased sensitivity to sedation (confusion or agitation), decreased alertness levels
Cardiovascular Increased effects of atherosclerosis of vessels and heart valves, decreased stroke volume with resulting decreased cardiac output,
decreased myocardial compliance, increased workload of heart, diminished peripheral pulses
Respiratory Decreased compliance and elasticity, decreased vital capacity, increased residual volume, less effective cough, decreased response to
hypercapnia
Renal Decreased glomerular filtration rate, increased risk of fluid and electrolyte imbalances
Gastrointestinal Increased presence of dentition problems, decreased intestinal mobility, decreased hepatic metabolism, increased risk of altered
nutritional states
Endocrine, hematologic, Increased incidence of diabetes, thyroid disorders, and anemia; decreased antibody response and cellular immunity
and immunologic
Integumentary Decreased skin turgor, increased capillary fragility and bruising, decreased elasticity
Miscellaneous Altered pharmacokinetics and pharmacodynamics, decreased range of motion of joints and extremities
Psychosocial Difficulty falling asleep and fragmented sleep patterns, increased incidence of depression and anxiety, cognitive impairment disorders,
difficulty with change

members or friends who may be abusive. Ask questions such
as “Is anyone hurting you?” or “Do you feel safe at home?”
in a non-threatening manner. Any suspicion of abuse or vul-
nerability should result in a consultation with social work to
determine additional assessments.
Physical Assessment by Body System
The physical assessment section is presented in the sequence
in which the combined system, head-to-toe approach, is fol-
lowed. Although content is presented as separate components,
generally the history questions are integrated into the physi-
cal assessment. The physical assessment section uses the tech-
niques of inspection, auscultation, and palpation. Although
percussion is a common technique in physical examinations,
it is infrequently used in progressive care patients.
Pain assessment is generally linked to each body sys-
tem rather than considered as a separate system category;
for example, if the patient has chest pain, assessment and
documentation of that pain is incorporated into the cardio-
vascular assessment. Rather than have general pain assess-
ment questions repeated under each system assessment, they
are presented here.
Pain and discomfort are clues that alert both the patient
and the progressive care nurse that something is wrong and
needs prompt attention. Pain assessment includes differen-
tiating acute from chronic pain, determining related physi-
ologic symptoms, and investigating the patient’s perceptions
and emotional reactions to the pain. Explore the qualities
and characteristics of the pain by using the questions listed
in Table 1-9. Pain is a subjective assessment, and progressive
care practitioners sometimes struggle with applying their
own values when attempting to evaluate the patient’s pain.
To resolve this dilemma, use the patient’s own words and
descriptions of the pain whenever possible and use a patient-
preferred pain scale (see Chapter 6, Pain and Sedation Man-
agement) to evaluate pain levels objectively and consistently.

Nervous System
TABLE 1-9. IDENTIFICATION OF SYMPTOM CHARACTERISTICS The nervous system is the master computer of all systems
Characteristic Sample Questions and is divided into the central and peripheral nervous sys-
tems. With the exception of the peripheral nervous system’s
Onset How and under what circumstances did it begin?
Was the onset sudden or gradual? Did it progress? cranial nerves, almost all attention in the acutely ill patient
Location Where is it? Does it stay in the same place or does it is focused on evaluating the central nervous system (CNS).
radiate or move around? The physiologic and psychological impact of an acute illness,
Frequency How often does it occur? in addition to pharmacologic interventions, frequently alters
Quality Is it dull, sharp, burning, throbbing, and so on? CNS functioning. The single most important indicator of
Intensity Rank pain on a scale (numeric, word description, cerebral functioning is the LOC.
FACES, FLACC) Assess pupils for size, shape, symmetry, and reactivity
Quantity How long does it last? to direct light. When interpreting the implication of altered
Setting What are you doing when it happens? pupil size, remember that certain medications such as atro-
Associated findings Are there other signs and symptoms that occur pine, morphine, or illicit drugs may affect pupil size. Base-
when this happens? line pupil assessment is important even in patients without a
Aggravating and What things make it worse? What things make it neurologic diagnosis because some individuals have unequal
Alleviating factors better?
or unreactive pupils normally. If pupils are not checked as a

baseline, a later check of pupils during an acute event could
inappropriately attribute pupil abnormalities to a pathophys-
iologic event.
Level of consciousness and pupil assessment are fol-
lowed by motor function assessment of the upper and lower
extremities for symmetry and quality of strength. Traditional
motor strength exercises include having the patient squeeze
the nurse’s hands and plantar flexing and dorsiflexing of the
patient’s feet. If the patient cannot follow commands, an esti-
mate of strength and quality of movements can be inferred
by observing activities such as pulling against restraints or
thrashing around. If the patient has no voluntary movement
or is unresponsive, check the gag reflex.
If head trauma is involved or suspected, check for
signs of fluid leakage around the nose or ears, differentiat-
ing between cerebral spinal fluid and blood (see Chapter 12,
Neurologic System). Complete cranial nerve assessment is
rarely warranted, with specific cranial nerve evaluation based
on the injury or diagnosis; for example, extraocular move-
ments are routinely assessed in patients with facial trauma.
Sensory testing is a baseline standard for spinal cord injuries,
extremity trauma, and epidural analgesia.
Now, it is a good time to assess mental status if the
patient is responsive. Assess orientation to person, place, and
time. Ask the patient to state their understanding of what is
happening. As you ask the questions, observe for eye con-
tact, pressured or muted speech, and rate of speech. Rate of
speech is usually consistent with the patient’s psychomotor
status. Underlying cognitive impairments such as dementia
and developmental delays are typically exacerbated during
an acute illness due to physiologic changes, medications,
and environmental changes. It may be necessary to ascertain
baseline level of functioning from the family.
It is also important to assess patients for the risk of a
fall. With the goal of increasing the mobility and indepen-
dence of progressive care patients, it is imperative that the
nurse understand the fall risk for each individual patient and
implement interventions to minimize the potential for a fall.
Laboratory data pertinent to the nervous system include
serum and urine electrolytes and osmolarity and urinary
specific gravity. Drug toxicology and alcohol levels may be
evaluated to rule out potential sources of altered LOC.
Cardiovascular System
The cardiovascular system assessment is directed at evaluat-
ing central and peripheral perfusion. Revalidate your admis-
sion quick check assessment of the blood pressure, heart
rate, and rhythm. If the patient is being monitored, assess the
ECG for T-wave abnormalities and ST-segment changes and
determine the PR, QRS, and QT intervals and the QTc mea-
surements. Note any abnormalities or indications of myocar-
dial damage, electrical conduction problems, and electrolyte
imbalances. Note the pulse pressure. If treatment decisions
will be based on the cuff pressure, blood pressure is taken
in both arms. If an arterial pressure line is in place, compare
the arterial line pressure to the cuff pressure. In either case,
COMPREHENSIVE INITIAL ASSESSMENT  11
TABLE 1-10. EDEMA RATING SCALE
Following the application and removal of firm digital pressure against the
tissue, the edema is evaluated for one of the following responses:
• 0 No depression in tissue
• +1 Small depression in tissue, disappearing in < 1 second
• +2 Depression in tissue disappears in < 1-2 seconds
• +3 Depression in tissue disappears in < 2-3 seconds
• +4 Depression in tissue disappears in ≥ 4 seconds
if a 10- to 15-mm Hg difference exists, a decision must be
made as to which pressure is the most accurate and will be
followed for future treatment decisions. If a different method
is used inconsistently, changes in blood pressure might be
inappropriately attributed to physiologic changes rather than
anatomic differences.
Note the color and temperature of the skin, with particu-
lar emphasis on lips, mucous membranes, and distal extremi-
ties. Also evaluate nail color and capillary refill. Inspect for
the presence of edema, particularly in the dependent parts of
the body such as feet, ankles, and sacrum. If edema is present,
rate the quality of edema by using a 0 to +4 scale (Table 1-10).
Auscultate heart sounds for S1 and S2 quality, intensity,
and pitch, and for the presence of extra heart sounds, mur-
murs, clicks, or rubs. Listen to one sound at a time, consis-
tently progressing through the key anatomic landmarks of
the heart each time. Note whether there are any changes with
respiration or patient position.
Palpate the peripheral pulses for amplitude and quality,
using the 0 to +4 scale (Table 1-11). Check bilateral pulses
simultaneously, except the carotid, comparing each pulse to its
partner. If the pulse is difficult to palpate, an ultrasound (Dop-
pler) device should be used. To facilitate finding a weak pulse
for subsequent assessments, mark the location of the pulse
with an indelible pen. It is also helpful to compare quality of
the pulses to the ECG to evaluate the perfusion of heartbeats.
Electrolyte levels, complete blood counts (CBCs), coag-
ulation studies, and lipid profiles are common laboratory
tests evaluated for abnormalities of the cardiovascular sys-
tem. Cardiac enzyme levels (troponin, creatine kinase MB,
β-natriuretic peptide) are obtained for any complaint of chest
pain or suspected chest trauma. Drug levels of commonly
used cardiovascular medications, such as digoxin, may be
warranted for certain types of arrhythmias. A 12-lead ECG
may be evaluated, either due to the chief reason for admis-
sion (eg, with complaints of chest pain, irregular rhythms, or
suspected myocardial bruising from trauma) or as a baseline
for future comparison if needed.
TABLE 1-11. PERIPHERAL PULSE RATING SCALE
• 0 Absent pulse
• +1 Palpable but thready; easily obliterated with light pressure
• +2 Normal; cannot obliterate with light pressure
• +3 Full
• +4 Full and bounding
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN