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SPARKS & TAYLOR'S

NURSING DIAGNOSIS
REFERENCE MANUAL
Tenth Edition
ACKNOWLEDGMENTS

I wish to express my appreciation to the nurses who contributed to the Nursing Diagnosis
&{~enu Manual, tenth edition. Their expertise and commitment to quality patient care made
this work possible. I am also grateful to Annette Ferran and Natasha Mcintyre from Wolters
Kluwer for their assistance, patience, and support.
I dedicate this book to all nurses, students to expert clinicians, who are dedicated. to provid-
ing quality patient care.
 CONTENTS

PREFACE v

ACKNOWLEDGEMENTS vi

OVERVIEW OF THE NURSING PROCESS viii

PARTI Adult Health 1

PART II Adolescent Health 407

PART Ill Child Health 437

PART IV Maternal-Neonatal Health 519
PARTY Geriatric health 641

PART VI Psychiatric and Mental Health 731

PART VII Community-Based Health 819

PART VIII Wellness 857

APPENDIX A A Selected Nursing Diagnoses by Medical Diagnosis 893

INDEX 933

NANDA INDEX 936

vii
 OVERVIEW OF THE NURSING PROCESS

The nursing process provides a framework for independent nursing action, promotes a consistent
structure for professional practice, and helps bring focus more precisely on each patient's health
care needa. The nursing process is a systematic method for making decisions and implementing
care. Steps in the nursjng process include
• assessing the patient's problems
• forming a diagnostic statement
• identifying expected outcomes
• creating a plan to achieve expected outcomes and solve the patient's problems
• implementing the plan or assigning others to implement it
• evaluating the plan's efn:ctiveness.
These phasea of the nursing proces8----GlS8essment, nursing diagnosis formation, outcome
identification, care planning, implementation, and evaluation--Qre dynamic, flexible, and
frequently overlap. The American Nurses Association has established these phases to meet
professional Standarda of Practice (American Nurses Association, 2015).
Becoming familiar with the nursing process has many benefits. It will allow you to apply
your knowledge and skills in an organized, goal-oriented manner. It will also enable you to
communicate about professional topics with colleagues from all clinical specialties and practice
settings. Using the nursing process is essential to documenting nursing's role in the provision
of comprehensive, quality patient care.
The recognition of the nursing process is an important development in the atruggle for greater
professional autonomy. By clearly de£ning those problems a nurse may treat independently,
the nursing process bas helped to dispel the notion that nursing practice is based solely on
carrying out the physician's orders.
Nursing remains in a state of professional evolution. Nurse researchers and expert prac-
titioners continue to develop a body of knowledge specific to the field. Nursing literature is
gradually providing direction to students and seasoned practitionen for evidence-based prac-
tice. A strong foundation in the nursing process will enable you to better assimilate emerging
concepts and to incorporate these concepts into your practice. (See Table 1, Ntming's Approach
to Problem Solving.)

ASSESSMENT
The 6.rst and most critical phase in the nursing process--QSSessmeot--am.sists of the patient
history, the physical enm.ination, and pertinent diagnostic studies. Nurses also collect informa-
tion about patient strengths and areas where potential problems e:xiat. The other nursing process
phaaes-nuraing diagnosis formation, outcome identification, planning care, implementation,
and evaluation-depend on the quality of the assessment data for their effectiveness.
viii
 OVERVIEW OF THE NURSING PROCESS ix

TABLE 1. NURSING'S APPROACH TO PROBLEM SOLVING

Dynamic and flexible, the phases of the nursing process resemble the steps th.at many other professions
rely on to identify and correct problems. Here's how the nursing process phases correspond to the standard
problem-solving method.
NURSING PROCESS PROBLEM-SOLVING METHOD
Assessment
• Collect and analyze subjective and objective data about • Recognize the problem
the patient's health problem • Learn about the problem by obtaining facts
Diagnosis
• State the health problem • State the nature of the problem
Outcome identification
• Identify expected outcomes • Establish goals and a time frame for achieving them
Planning
• Write a care plan that includes the nursing interven- • Think of and select ways to achieve goals and solve the
tions designed to achieve expected outcomes problem
Implementation
• Put the t:are plan into action • Act on ways to solve the problem
• Document the actions taken and their results
Evaluation
• Crifa:ally examine the results achieved • Decide if the actions taken have effectively solved the
• Review and revise the care plan as needed problem

A properly recorded initial assessment provides

• a way to communicate patient information to other caregivers
• a method of documenting initial baseline data
• a foundation on which to build an effective care plan
Your initial patient assessment begins with the collection of data (patient history, physical
examination findings, and diagnostic study data) and ends with a statement of the patient's
deficiency in, risk for, or readiness for enhancement of a specific problem that is written as
the nursing diagnosis.

Building a Database
The information you collect when taking the patient's history, performing a physical examina-
tion, and analyzing test results serves as your assessment database. Your goal is to gather and
record information that will be most helpful in assessing your patient. You can't realistically
collect-or use-all the information th.at exists about the patient. To limit your database ap-
propriately, ask yourself these questions:
• What data do I want to collect?
• How should I collect the data?
• How should I organize the data to make care planning decisions?
Your answers will help you to be selective in collecting meaningful data during patient
assessment.
X OVERVIEW OF THE NURSING PROCESS

The well-defined database for a patient may begin with admission signs and symptoms,
chief complaint, or medical diagnosis. It may also center on the type of patient care given in
a specific setting, such as the intensive care unit (ICU), the emergency department (ED), or
an outpatient care center. For example, you wouldn't ask a trauma patient in the ED about
a family history of breast cancer, nor would you perform a routine breast examination. You
would, however, do these types of assessment during a comprehensive health checkup in an
outpatient care setting.
If you work in a setting where patients with similar diagnoses are treated, choose your
database from information pertinent to this specific patient population. Even when addressing
patients with similar diagnoses, complete a thorough assessment to make sure unanticipated
problems don't go unnoticed.

Colleding Subjedive and Objedive Data

The assessment data you collect and analyze fall into two important categories: subjective and
objective. The patient's history, embodying a personal perspective of problems and strengths,
provides subjective data. It's your most important assessment data source. Because it's also the
most subjective source of patient information, it must be interpreted carefully.
In the physical examination of a patient-involving inspection, palpation, percussion, and
auscultation-you collect objective data about the patient's health status or about the patho-
logic processes that may be related to illness or injury. In addition to adding to the patient's
database, this information helps you interpret the patient's history more accurately by providing
a basis for comparison. Use it to validate and amplify the historical data. However, don't allow
the physical examination to assume undue importance-formulate your nursing diagnosis by
considering all the elements of your assessment, not just the examination.
Laboratory test results are another objective form of assessment data and the third essential
element in developing your assessment. Laboratory values will help you to interpret-and,
usually, clarify-your history and physical examination findings. The advanced technology
used in laboratory tests enables you to assess anatomic, physiologic, and chemical processes
that can't be assessed subjectively or by physical examination alone. For example, if the patient
complains of fatigue (history) and you observe conjunctival pallor (physical examination),
check the patient's hemoglobin level and hematocrit (laboratory data).
Both subjective (history) and objective (physical examination and laboratory test results)
data are essential for comprehensive patient assessment. They validate each other and together
provide more data than either can provide alone. By considering history, physical examination,
and laboratory data in their appropriate relationships to one another, you'll be able to develop
a nursing diagnosis on which to formulate an effective care plan.

Taking a Complete Health History

This portion of the assessment consists of the subjective data you collect from the patient. A
complete health history provides the following information about a patient:
• Biographical data, including ethnic, cultural, health seeking, and spiritual factors
• Chief complaint (or concern)
• History of present illness (or current health status)
• Health promotion behaviors, motivation
• Past health history
• Family medical history
• Psychosocial history
• Activities of daily living (ADLs)
• Review of systems
 OVERVIEW OF THE NURSING PROCESS Xi

Follow this orderly format in taking the patient's history, but allow for modifications based
on the patient's chief complaint or concern. For example, the health history of a patient with a
localized allergic reaction will be much shorter than that of a patient who complains vaguely
of mental confusion and severe headaches.
If the patient has a chief complaint, use information from the health history to decide whether
problems stem from physiologic causes or psychophysiologic maladaptation and how nursing
interventions may help. The depth of such a history depends on the patient's cooperation and
your skill in asking insightful questions.
A patient may request a complete physical checkup as part of a periodic (perhaps annual)
health maintenance routine. Such a patient may not have a chief complaint. Therefore, this
patient's health history should be comprehensive with detailed information about lifestyle,
self-image, family and other interpersonal relationships, and degree of satisfaction with cur-
rent health status.

BOX 1. USING AN ASSESSMENT CHECKLIST

Use an assessment checklist such as this to ensure that you cover all key points during your health history
interview. Although the format may vary from one facility to another, all assessment checklist guides in-
clude the same key elements.
• Reason for hospita/.ization or chief complaint: As patient sees it
• Dumtion of this problem: AB patient recalls it (Has it affected the patient's lifestyle?)
• Other illnases and previous expniena with hospita/.ization(s): Reason, date(s), results, impressions of pre-
vious hospitalizations, problems encountered, effect of this hospitalization on education, family, child care,
employment, finances
• Observation of patient's condition: Level of consciousness, well-nourished, healthy, color, skin turgor, senses,
headaches, cough, syncope, nausea, seizures, edema, lumps, bruises or bleeding, inflammation, integrity of
skin, pressure areas, temperature, range of motion, unusual sensations, paralysis, odors, discharges, pain
• Mental and emotional status: Cooperative, understanding, anxious, language, expectations, feelings about
illness, state of consciousness, mood, self-image, reaction to stress, rapport with interviewer and staff, compat-
ibility with roommate
• Review ofsystems: Neurologic, EENT (eye, ear, nose, throat), pulmonary, cardiovascular, GI (gastrointestinal),
GU (genitourinary), skin, reproductive, musculoskeletal, and so forth
• Allergies: Food, drugs, other allergens, type of reaction
• Medication: Dosage, why taken, when taken, last dose, does the patient have it, any others taken occasionally,
recently, why, use of over-the-counter drugs or cough preparations, use of alcohol or recreational drugs
• Prostheses: Pacemaker, intermittent positive-pressure breathing unit, tracheostomy tube, drainage tubes, feed-
ing tube, catheter, ostomy appliance, breast form, hearing aid, glasses or contact lenses, dentures, false eye,
prosthetic limb, cane, brace, walker, does the patient have the device, need anything
• Hygiene patums: Dentures, gums, teeth, bath or shower, when taken
• Rest and sleep pattnns: Usual times, aids, difficulties
• Activity status: Self-care, ambulatory, aids, daily exercise
• Bladder and bowel patterns: Continence, frequency, nocturia, characteristics of stools and urine, discharge,
pain, ostomy, appliances, who cares for these, laxatives, medications
• Meals and diet: Feeds self, diet restrictions (therapeutic and cultural or preferential), frequency, snacks, aller-
gies, dislikes, fad diets, usual dietary intake
• Health pnu;t'ias: Breast self-examination, physical examination, Papanicolaou test, testicular self-examina-
tion, digital rectal examination, smoking, electrocardiogram, annual chest X-ray, practices related to other
conditions, such as glaucoma testing, urine testing, weight control
• Lifestyle: Parent, family, number of children, residence, occupation, recreation, diversion, interests, financial
status, religion, sexuality, education, ethnic background, living environment
• 'fypical day profile: As patient describes it
• Informant: From whom did you obtain this information, patient, family, old records, ambulance driver
xii OVERVIEW OF THE NURSING PROCESS

Be sure to record health history data in an organized fashion to ensure the information will
be meaningful to everyone involved in the patient's care. Some health care facilities provide
patient questionnaires or computerized checklists. (See Box 1, Using an Assessment Check-
list.) These forms make history-taking easier, but they aren't always available. Therefore, you
must know how to take a comprehensive health history without them. This is easy to do if
you develop an orderly and systematic method of interviewing. Ask the history questions in
the same order every time. With experience, you'll know which types of questions to ask in
specific patient situations.

REVIEW OF SYSTEMS
When interviewing the patient, use this review of systems as a guide.
• General: Overall state of health, ability to carry out ADLs, weight changes, fatigue, exer-
cise tolerance, fever, night sweats, repeated infections
• Skin: Changes in color, pigmentation, temperature, moisture, or hair distribution; erup-
tions; pruritus; scaling; bruising; bleeding; dryness; excessive oiliness; growths; moles;
scars; rashes; scalp lesions; brittle, soft, or abnormally formed nails; cyanotic nail beds;
pressure ulcers
• Head: Trauma, lumps, alopecia, headaches
• Eyes: Nearsightedness, farsightedness, glaucoma, cataracts, blurred vision, double vision,
tearing, burning, itching, photophobia, pain, inflammation, swelling, color blindness,
injuries (also ask about use of glasses or contact lenses, date of last eye examination, and
past surgery to correct vision problems)
• Ears: Deafness, tinnitus, vertigo, discharge, pain, and tenderness behind the ears, mastoid-
itis, otitis or other ear infections, earaches, ear surgery
• Nose: Sinusitis, discharge, colds, or coryza more than four times per year; rhinitis;
trauma; sneezing; loss of sense of smell; obstruction; breathing problems; epistaxis
• Mouth and throat: Changes in color or sores on tongue, dental caries, loss of teeth,
toothaches, bleeding gums, lesions, loss of taste, hoarseness, sore throats (streptococcal),
tonsillitis, voice changes, dysphagia, date of last dental checkup, use of dentures, bridges,
or other dental appliances
• Neck: Pain, stiffness, swelling, limited movement, or injuries
• Breasts: Change in development or lactation pattern, trauma, lumps, pain, discharge from
nipples, gynecomastia, changes in contour or in nipples, history of breast cancer (also ask
whether the patient knows how to perform breast self-examination)
• Cardiovascular: Palpitations, tachycardia, or other rhythm irregularities; pain in chest;
dyspnea on exertion; orthopnea; cyanosis; edema; ascites; intermittent claudication; cold
extremities; phlebitis; orthostatic hypotension; hypertension; rheumatic fever (also ask
whether an dectrocardiogram has been performed recently)
• Respiratory: Dyspnea, shortness of breath, pain, wheezing, paroxysmal nocturnal dys-
pnea, orthopnea (number of pillows used), cough, sputum, hemoptysis, night sweats,
emphysema, pleurisy, bronchitis, tuberculosis (contacts), pneumonia, asthma, upper
respiratory tract infections (also ask about results of chest X-ray and tuberculin skin
test)
• Gastrointestinal: Changes in appetite or weight, dysphagia, nausea, vomiting, heartburn,
eructation, flatulence, abdominal pain, colic, hematemesis, jaundice (pain, fever, intensity,
duration, color of urine), stools (color, frequency, consistency, odor, use of laxatives),
hemorrhoids, rectal bleeding, changes in bowel habits
• Renal and genitourinary: Color of urine, polyuria, oliguria, nocturia (number of times
per night), dysuria, frequency, urgency, problem with stream, dribbling, pyuria, retention,
 OVERVIEW OF THE NURSING PROCESS Xiii

passage of calculi or gravel, sexually transmitted disease (discharge), infections, perinea!

rashes and irritations, incontinence (stress, functional, total, reflex, urge), protein or sugar
ever found in urine
• Reproductive: Male-lesions, impotence, prostate problems (also ask about use of con-
traceptives and whether the patient knows how to perform a testicular self-examination);
female-irregular bleeding, discharge, pruritus, pain on intercourse, protrusions, dysmen-
orrhea, vaginal infections (also ask about number of pregnancies; delivery dates; compli-
cations; abortions; onset, regularity, and amount of flow during menarche; last normal
menses; use of contraceptives; date of menopause; last Papanicolaou test)
• Neurologic: Headaches, seizures, fainting spells, dizziness, tremors, twitches, aphasia, loss
of sensation, weakness, paralysis, numbness, tingling, balance problems
• Psychiatric: Changes in mood, anxiety, depression, inability to concentrate, phobias, sui-
cidal or homicidal thoughts, hallucinations, delusions
• Musculoskeletal: Muscle pain, swelling, redness, pain in joints, back problems, injuries
(such as fractured bones, pulled tendons), gait problems, weakness, paralysis, deformities,
range of motion, contractures
• Hematopoietic: Anemia (type, degree, treatment, response), bleeding, fatigue, bruising
(also ask whether patient is receiving anticoagulant therapy)
• Endocrine and metabolic: Polyuria, polydipsia, polyphagia, thyroid problem, heat or cold
intolerance, excessive sweating, changes in hair distribution and amount, nervousness,
swollen neck (goiter), moon face, buffalo hump

ENSURING A THOROUGH HISTORY

When documenting the health history, be sure to record both negative and positive findings;
that is, note the absence of symptoms that other history data indicate might be present.
For example, if a patient reports abdominal pain and burning, ask about experiencing
nausea and vomiting or noticing blood in stools. Record the presence or absence of these
symptoms.
Remember that the information you record will be used by others who will be caring for the
patient. Recorded information can be used as a legal document in a liability case, a malpractice
suit, or an insurance disability claim. With these considerations in mind, record history data
thoroughly and precisely. Continue your questioning until you're satisfied that you've recorded
sufficient detail. Don't be satisfied with inadequate answers, such as "a lot" or "a little"; such
subjective terms must be explained within the patient's context to be meaningful. If taking
notes seems to make the patient anxious, explain the importance of keeping a written record.
To facilitate accurate recording of the patient's answers, familiarize yourself with standard
history data abbreviations.
When you complete the patient's health history, it becomes part of the permanent written
record. It will serve as a subjective database with which you and other health care profes-
sionals can monitor the patient's progress. Remember that history data must be specific and
precise. Avoid generalities. Instead, provide pertinent, concise, detailed information that will
help determine the direction and sequence of the physical examination-the next phase in
your patient assessment.

Physical Examination
After taking the patient's health history, the next step in the assessment process is the physical
examination. During this assessment phase, you obtain objective data that usually confirm or
rule out suspicions raised during the health history interview.
xiv OVERVIEW OF THE NURSING PROCESS

Use four basic techniques to perform a physical examination: inspection, palpation, percus-
sion, and auscultation (IPPA). These skills require you to use your senses of sight, hearing, touch,
and smell to formulate an accurate appraisal of the structures and functions of body systems.
Using IPPA skills effectively lessens the chances that you'll overlook something important during
the physical examination. In addition, each examination technique collects data that validate
and amplify data collected through other IPPA techniques.
Accurate and complete physical assessments depend on two interrelated elements. One is
the critical act of sensory perception, by which you receive and perceive external stimuli. The
other element is the conceptual, or cognitive, process by which you relate these stimuli to your
knowledge base. This two-step process gives meaning to your assessment data.
Develop a system for assessing patients that identifies problem areas in priority order.
By performing physical assessments systematically and efficiently instead of in a random or
indiscriminate manner, you'll save time and identify priority problems quickly. First, choose
an examination method. The most commonly used methods for completing a total systematic
physical assessment are head-to-toe and major body systems.
The head-to-toe method is performed by systematically assessing the patient by-as the
name suggests-beginning at the head and working toward the toes. Examine all parts of one
body region before progressing to the next region to save time and to avoid tiring the patient
or yourself. Proceed from left to right within each region so you can make symmetrical com-
parisons; that is, when examining the head, proceed from the left side of the head to the right
side. After completing both sides of one body region, proceed to the next.
The major body systems method of examination involves systematically assessing the patient
by examining each body system in priority order or in an established sequence.
Both the head-to-toe and the major body systems methods are systematic and provide a
logical, organized framework for collecting physical assessment data. They also provide the
same information; therefore, neither is more correct than the other. Choose the method (or a
variation of it) that works well for you and is appropriate for your patient population. Follow
this routine whenever you assess a patient, and try not to deviate from it.
To decide which method to use, first determine whether the patient's condition is life-
threatening. Identifying the priority problems of a patient suffering from a life-threatening
illness or injury-for example, severe trauma, a heart attack, or GI hemorrhage--is essential
to preserve the patient's life and function and prevent additional damage.
Next, identify the patient population to which the patient belongs, and take the common
characteristics of that population into account in choosing an examination method. For ex-
ample, elderly or debilitated patients tire easily; for these patients, you should select a method
that requires minimal position changes. You may also defer parts of the examination to avoid
tiring the patient.
Try to view the patient as an integrated whole rather than as a collection of parts, re-
gardless of the examination method you use. Remember, the integrity of a body region may
reflect adequate functioning of many body systems, both inside and outside the region in
question. For example, the integrity of the chest region may provide important clues about the
functioning of the cardiovascular and respiratory systems. Similarly, the integrity of a body
system may reflect adequate functioning of many body regions and of the various systems
within these regions.
You may want to plan your physical examination around the patient's chief complaint or
concern. To do this, begin by examining the body system or region that corresponds to the chief
complaint. This allows you to identify priority problems promptly and reassures the patient
that you're paying attention to his chief complaint.
Physical examination findings are crucial to arriving at a nursing diagnosis and, ultimately, to
developing a sound nursing care plan. Record your examination results thoroughly, accurately,
 OVERVIEW OF THE NURSING PROCESS XV

BOX 2. DOCUMENTATION TIPS

Remember these rules about documenting your initial assessment:

• Always document your findings as soon as possible after you take the health history and perform the physical
examination.
• Complete documentation of your assessment away from the patient's bedside. Jot down only key points while
you're with the patient.
• If you're using an assessment form, answer every question. If a question doesn't apply to your patient, write
"NIA" or "not applicableD in the space. (Unanswered questions give the appearance that the question was not
assessed.)
• Focus your questions on areas that relate to the patient's chief complaint. Record information that has signifi-
cance and will help you build a care plan.
• If you delegate the job of filling out the first section of the form to another nurse or an ancillary nursing per-
son, remember-you must review the information gathered and validate it if you aren't sure it's correct.
• Always accept accountability for your assessment by signing your name to the areas you've completed.
• Always directly quote the patient or family member who gave you the information if you fear that summariz-
ing will lose some of its meaning.
• Always write or print legibly, in ink.
• Be concise, specific, and exact when you describe your physical findings.
• Always go back to the patient's bedside to clarify or validate information that seems incomplete.

and clearly. Although some examiners don't like to use a printed form to record physical as-
sessment findings, preferring to work with a blank paper, others believe that standardized
data collection forms can make recording physical examination results easier. These forms
simplify comprehensive data collection and documentation by providing a concise format for
outlining and recording pertinent information. They also remind you to include all essential
assessment data.
When documenting, describe exactly what you've inspected, palpated, percussed, or
auscultated. Don't use general terms, such as normal, abnormal, good, or poor. Instead, be
specific. Include positive and negative findings. Try to document as soon as possible after
completing your assessment. Remember that abbreviations aid conciseness. (See Box 2,
Documentation Tips.)

NURSING DIAGNOSIS
According to NANDA International, the nursing diagnosis is a "clinical judgment concern-
ing a human response to health conditions/life processes, or vulnerability for that response,
by an individual, family, group, or community. A nursing diagnosis provides the basis for
selection of nursing interventions to achieve outcomes for which the nurse has account-
ability" (Herdman & Kamitsuru, 2014, p. 464 ). The nursing diagnosis must be supported
by clinical information obtained during patient assessment. (See Box 3, Nursing Diagnoses
and the Nursing Process.)
Each nursing diagnosis describes a patient problem that a nurse can legally manage. Becom-
ing familiar with nursing diagnoses will enable you to better understand how nursing practice
is distinct from medical practice. Although the identification of problems commonly overlaps
in nursing and medicine, the approach to treatment dearly differs. Medicine focuses on curing
disease; nursing focuses on holistic care that includes care and comfort. Nurses can indepen-
dently diagnose and treat the patient's response to illness, certain health problems and risk
for health problems, readiness to improve health behaviors, and the need to learn new health
xvi OVERVIEW OF THE NURSING PROCESS

BOX 3. NURSING DIAGNOSES AND THE NURSING PROCESS

When first described, the nursing process included only assessment, planning, implementation, and evalu-
ation. Howevei; during the past three decades, several important events have helped to establish diagnosis
as a distinct part of the nursing process.
• The American Nurses Association (ANA), in its 1973 publication Standards of Nursing Practice, mentioned
nursing diagnosis as a separate and definable act performed by the registered nurse. In 1991, the ANA pub-
lished its revised standards of clinical practice, which continued to list nursing diagnosis as a distinct step of
the nursing process.
• Individual states passed nurse practice acts that listed diagnosis as part of the nurse's legal responsibility.
• In 1973, the North American Nursing Diagnosis Association, now NANDA International, began a formal ef-
fort to classify nursing diagnoses. NANDA International continues to meet biennially to review proposed new
nursing diagnoses and examine applications of nursing diagnoses in clinical practice, education, and research.
Their most recent meeting was held in May 2012 in Houston, Texas. NANDA International also publishes
Nursing Diagnoses: Definitions and Classification 2015-2017, a complete list of nursing diagnoses, defini-
tions, and defining characteristics. Currently, members of NANDA-I are working in cooperation with the
ANA and the International Council of Nurses to develop an International Classification of Nursing
Practice.
• The emergence of the computer-based patient record has underscored the need for a standardized nomencla-
ture for nursing.

information. Nurses comfort, counsel, and care for patients and their families until they're
physically, emotionally, and spiritually ready to provide self-care.

Developing Your Diagnosis

The nursing diagnosis expresses your professional judgment of the patient's clinical status,
responses to treatment, and nursing care needs. In effect, the nursing diagnosis defines the
practice of nursing. Translating the patient's history, physical examination, and laboratory
data into a nursing diagnosis involves organizing the data into clusters and interpreting what
the clusters reveal about the patient's ability to meet the basic needs. In addition to identifying
the patient's needs in coping with the effects of illness, consider what assistance the patient
requires to grow and develop to the fullest extent possible.
Your nursing diagnosis describes the cluster of signs and symptoms indicating an actual
or potential health problem that you can identify-and that your care can resolve. Nursing
diagnoses that indicate potential health problems can be identified by the words "risk for,"
which appear in the diagnostic label. There are also nursing diagnoses that focus on prevention
of health problems and enhanced wellness.
Creating your nursing diagnosis is a logical extension of collecting assessment data. In your
patient assessment, you asked each history question, performed each physical examination
technique, and considered each laboratory test result because it provided evidence of how the
patient could be helped by your care or because the data could affect nursing care.
To develop the nursing diagnosis, use the assessment data you've collected to develop a
problem list. Less formal in structure than a fully developed nursing diagnosis, this list describes
the patient's problems or needs. It's easy to generate such a list if you use a conceptual model
or an accepted set of criterion norms. Examples of such norms include normal physical and
psychological development and Gordon's functional health patterns.
You can identify the patient's problems and needs with simple phrases, such as poor circula-
tion, high fever. or poor hydration. Next, prioritize the problems on the list, and then develop
the working nursing diagnosis.
 OVERVIEW OF THE NURSING PROCESS xvii

Writing a Nursing Diagnosis

Some nurses are confused about how to document a nursing diagnosis because they think the
language is too complex. However. by remembering the following basic guidelines, you can
ensure that your diagnostic statement is correct:
• Use proper terminology that reflects the patient's nursing needs.
• Make your statement concise so it's easily understood by other health care team members.
• Use the most precise words possible.
• Use a problem and cause format, stating the problem and its related cause.
Whenever possible, use the terminology recommended by NANDA-I.
NANDA-I diagnostic headings, when combined with suspected etiology and supported by
defining characteristics or risk factors (Herdman & Kamitsuru, 2014, p. 26), provide a clear
picture of the patient's needs. Thus, for clarity in charting, start with one of the NANDA-I
categories as a heading for the diagnostic statement. The category can reflect an actual or
potential problem. Consider this sample diagnosis:
• Heading: Impaired physical mobility
• Etiology: Related to pain and discomfort following surgery
• Signs and symptoms (these are the defining characteristics or risk factors): "I can't walk
without help."' Patient hasn't ambulated since surgery on __ (give date and time). Range
of motion limited to 10 degrees flexion in the right hip. Patient can't walk 3 feet from the
bed to the chair without the help of two nurses.
• This format links the patient's problem to the etiology without stating a direct cause-and-
effect relationship (which may be hard to prove). Remember to state only the patient's
problems and the probable origin. Omit references to possible solutions. (Your solutions
will derive from your nursing diagnosis, but they aren't part of it.)

Avoiding Common Errors

One major pitfall in developing a nursing diagnosis is writing one that nursing interventions
can't treat. Errors can also occur when nurses take shortcuts in the nursing process, either
by omitting or hurrying through assessment or by basing the diagnosis on inaccurate assess-
ment data.
Keep in mind that a nursing diagnosis is a statement of a health problem that a nurse is
licensed to treat-a problem for which you'll assume responsibility for therapeutic decisions
and accountability for the outcomes. A nursing diagnosis is not a
• diagnostic test ("schedule for cardiac angiography")
• piece of equipment ("set up intermittent suction apparatus")
• problem with equipment ("the patient has trouble using a commode")
• nurse's problem with a patient ("Mr. Jones is a difficult patient; he's rude and won't take
his medication.")
• nursing goal ("encourage fluids up to 2,000 mUday")
• nursing need ("I have to get through to the family that they must accept the fact that
their father is dying.")
• medical diagnosis ("cervical cancer"')
• treatment ("catheterize after each voiding for residual urine").
At first, these distinctions may not be cleac The following examples should help clarify
what a nursing diagnosis is:
• Don't state a need instead of a problem.
- Incorrect: Fluid replacement related to fever
- Correct: Deficient fluid volume related to fever
xviii OVERVIEW OF THE NURSING PROCESS

• Don't reverse the two parts of the statement.

- Incorrect: Lack of understanding related to noncompliance with diabetic
diet
- Correct: Noncompliance with diabetic diet related to lack of understanding
• Don't identify an untreatable condition instead of the problem it indicates (which
can be treated}.
- Incorrect: Inability to speak related to laryngectomy
- Correct: Social isolation related to inability to speak because of laryngectomy
• Don't write a legally inadvisable statement.
- Incorrect: Skin integrity impairment related to improper positioning
- Correct: Impaired skin integrity related to immobility
• Don't identify as unhealthful a response that would be appropriate, allowed for. or
culturally acceptable.
- Incorrect: Anger related to terminal illness
- Correct: Ineffective therapeutic regimen management related to anger over terminal
illness
• Don't make a tautological statement (one in which both parts of the statement say the
same thing).
- Incorrect: Pain related to alteration in comfort
- Correct: Acute pain related to postoperative abdominal distention and
anxiety
• Don't identify a nursing problem instead of a patient problem.
- Incorrect: Difficulty suctioning related to thick secretions
- Correct: Ineffective airway clearance related to thick tracheal secretions

How Nursing and Medical Diagnoses Differ

You assess your patient to obtain data in order to make a nursing diagnosis, just as the physician
examines a patient to establish a medical diagnosis. It is important to understand the differences
between the two and remember that they sometimes overlap. You perform a complete assess-
ment to identify patient problems that nursing interventions can help resolve; your nursing
diagnoses state these problems. (Some problems may be secondary to medical treatment.) If
you plan your care of a patient around only the medical aspects of an illness, you'll probably
overlook significant problems.
For example, suppose the patient's medical diagnosis is a fractured femur. In your assess-
ment, take a careful history. Include questions to determine whether the patient has adequate
financial resources to cope with prolonged disability. To assess the patient's capacity to adjust
to the physical restrictions caused by the disability, gather data about his or her previous
lifestyle.
Suppose your physical examination of this patient-in addition to uncovering signs and
symptoms pertaining to the medical diagnosis-reveals actual or potential skin breakdown
secondary to immobility. Your nursing diagnoses, in that case, may include home maintenance
management impairment, diversional activity deficit (related to prolonged immobility), and
risk for skin integrity impairment.
The care plan you prepare for this patient should include the nursing interventions sug-
gested by your nursing diagnoses as well as the nursing actions necessary to fulfill the patient's
medical treatment plan. When integrated into a care plan, the nursing and medical diagnoses
describe the complete nursing care the patient needs. See Box 4 for examples of differences
between medical and nursing diagnoses.
 OVERVIEW OF THE NURSING PROCESS xix

BOX 4. EXAMPLES OF MEDICAL AND NURSING DIAGNOSES

Study the following examples here to better understand the difference between medical and nursing
diagnoses:
• Frank Smith, age 67, complains of "stubborn, old muscles."' He has difficulty walking, as you can see by his
shuffling gait. During the interview, Mr. Smith speaks in a monotone and seems very depressed. Physical ex-
amination shows a pill-rolling hand tremor. Laboratory tests reveal a decreased dopamine level.
- Medical diagnosis: Parkinson's disease
- Nursing diagnoses: hnpaired physical mobility related to decreased muscle control; disturbed body image
related to physical alterations; deficient knowledge related to lack of information about progressive nature
of illness
• For 5 consecutive days, Judy Wilson, age 26, has had sporadic abdominal cramps of increasing intensity. Most
recently, the pain has been accompanied by vomiting and a slight fever. Your examination reveals rebound
tenderness and muscle guarding.
- Medical diagnosis: Appendicitis
- Nursing diagnoses: Acute pain related to biologic agents; deficient fluid volume related to
vomiting
• During an extensive bout with respiratory tract infections, Tom Bradley, age 7, complains of throbbing ear
pain. Tom's mother notes his hearing difficulty and his fear of the pain and possible hearing loss. On inspec-
tion, his tympanic membrane appears red and bulging.
- Medical diagnosis: Acute suppurative otitis media
- Nursing diagnoses: Acute pain related to swollen tympanic membrane; fear related to progressive
hearing loss.

OUTCOME IDENTIFICATION
During this phase of the nursing process, you will identify expected outcomes for the patient.
Derived from the patient's nursing diagnoses, expected outcomes are goals that are measur-
able, patient focused, realistic, cleat; concise, and time limited. These goals may be short- or
long-term. Short-term goals include those of immediate concern that can be achieved quickly.
Long-term goals take more time to achieve and usually involve prevention, patient teaching,
and rehabilitation.
In many cases, you can identify expected outcomes by converting the nursing diagnosis
into a positive statement. For instance, for the nursing diagnosis "impaired physical mobility
related to a fracture of the right hip," the expected outcome might be "The patient will ambulate
independently before discharge."
When writing the care plan, state expected outcomes in terms of the patient's behavior-for
example, "the patient correctly demonstrates turning, coughing, and deep breathing." Also,
identify a target time or date by which the expected outcomes should be accomplished. The
expected outcomes will serve as the basis for evaluating your nursing interventions.
If possible, consult with the patient and the patient's family when establishing expected
outcomes. As the patient progresses, expected outcomes should be increasingly directed toward
planning for discharge and follow-up care.
Outcome statements should be tailored to your practice setting. For example, on the ICU,
you may focus on maintaining hemodynamic stability, whereas on a rehabilitation unit, you
would focus on maximizing the patient's independence and preventing complications. (See
Box 5, Understanding NOC.)
XX OVERVIEW OF THE NURSING PROCESS

BOX 5. UNDERSTANDING NOC

The Nursing Outcomes Classification (NOC) is a standardized language of patient or client outcomes that
was developed by a nursing research team at the University of Iowa. It contains 385 outcomes organized
into 33 classes and 7 domains. Each outcome has a definition, list of measurable indicators, and refer-
ences. The outcomes are research based, and studies are ongoing to evaluate their reliability, validity, and
sensitivity. More information about NOC can be found at the Center for Nursing Classification and Clini-
cal Effectiveness (www.nursing.uiowa.edu/cnc).

Writing Expeded Outcome Statements

Expected outcomes must be stated in measurable terms. Measurable terms describe observ-
able results and provide the criteria for success; they clearly describe the expected result after
interventions are implemented. Avoid ambiguous language such as better, improve, or decrease
because such terms are difficult to quantify. When writing expected outcomes in your care
plan, always start with a specific action verb that focuses on the patient's behavior. By telling
your reader how the patient should look, walk, eat, drink, turn, cough, speak, or stand, for
example, you give a clear picture of how to evaluate progress.
Avoid starting expected outcome statements with allow, let, enable, or similar verbs. Such
words focus attention on your own and other health care team members' behavior-not on
the patient's.
With many documentation formats, you won't need to include the phrase "The patient
will..." with each expected outcome statement. You will, however, have to specify which person
the goals refer to when family, friends, or others are directly concerned.
Make sure target dates are realistic. Be flexible enough to adjust the date if the patient needs
more time to respond to your interventions.

PLANNING
The nursing care plan refers to a written plan of action designed to help you deliver quality
patient care. It includes relevant nursing diagnoses, expected outcomes, and nursing interven-
tions. Keep in mind that the care plan usually forms a permanent part of the patient's health
record and will be used by other members of the nursing team. The care plan may be integrated
into an interdisciplinary plan for the patient. In this instance, clear guidelines should outline
the role of each member of the health care team in providing care.

Benefits of a Care Plan

To provide quality care for each patient, you must plan and direct that care. Writing a care
plan allows you to document the scientific method used throughout the nursing process. In the
care plan, you summarize the patient's problems and needs (as nursing diagnoses) and identify
appropriate nursing interventions and expected outcomes. A care plan that's well conceived
and properly written helps decrease the risk of incomplete or incorrect care by
• Giving direction: A written care plan gives direction by showing colleagues the goals you
have set for the patient and gives clear instructions for assisting in goal achievement. The
care plan also makes clear exactly what to document on the patient's progress notes. For
instance, the plan should list what observations to make and how often, what nursing
 OVERVIEW OF THE NURSING PROCESS XXi

measures to take and how to implement them, and what to teach the patient and the pa-
tient's family before discharge.
• Providing continuity of care: A written care plan identifies the patient's needs to each
caregiver and tells what must be done to meet those needs. With this information, nurses
caring for the patient at different times can adjust their routines to meet the patient's care
demands. A care plan also provides caregivers with specific instructions on patient care,
eliminating the confusion that can exist. If the patient is discharged from your health care
facility to another, your care plan can help ease this transition.
• Establishing communication between you and other nurses who will care for the patient,
between you and health care team members in other departments, and between you and
the patient: Soliciting the patient's input as you develop the care plan demonstrates that
you value the patient's opinions and feelings. By reviewing the care plan with other health
care team members, and with other nurses, you can regularly evaluate the patient's re-
sponse or lack of response to the nursing care and medical regimen.
• Serving as a key for patient care assignments: If you're a team leader, you may want to
delegate some specific routines or duties described in each nursing intervention-not all
of them need your professional attention.

Reviewing the Planning Stages

Formulating the care plan involves three stages:
• Assigning priorities to the nursing diagnoses: Any time you develop more than one nurs-
ing diagnosis for the patient, you must assign priorities to them and begin your care plan
with those having the highest priority. High-priority nursing diagnoses involve the pa-
tient's most urgent needs (such as emergency or immediate physical needs). Intermediate-
priority diagnoses involve nonemergency needs, and low-priority diagnoses involve needs
that don't directly relate to the patient's specific illness or prognosis.
• Selecting appropriate nursing actions (interventions): Next, you'll select one or more
nursing interventions to achieve each of the expected outcomes identified for the patient.
For example, if one expected outcome statement reads, "The patient will transfer to chair
with assistance," the appropriate nursing interventions include placing the wheelchair fac-
ing the foot of the bed and assisting the patient to stand and pivot to the chair. If another
expected outcome statement reads, "The patient will express feelings related to recent
injury," appropriate interventions might include spending time with the patient each shift,
conveying an open and nonjudgmental attitude, and asking open-ended questions.
• Documenting the nursing diagnoses, expected outcomes, nursing interventions, and
evaluations on the care plan: Reviewing the second part of the nursing diagnosis state-
ment (the part describing etiologic factors) may help guide your choice of nursing inter-
ventions. For example, for the nursing diagnosis "Risk for injury related to inadequate
blood glucose levels," you would determine the best nursing interventions for maintain-
ing an adequate blood glucose level. Typical interventions for this goal include observing
the patient for evidence of hypoglycemia and providing an appropriate diet. Try to think
creatively during this step in the nursing process. It's an opportunity to describe exactly
what you and your patient would like to have happen and to establish the criteria against
which you'll judge further nursing actions.
The planning phase culminates when you write the care plan and document the nursing
diagnoses, expected outcomes, nursing interventions, and evaluations for expected outcomes.
Write your care plan in concise, specific terms so that other health care team members can
follow it. Keep in mind that because the patient's problems and needs will change, you'll have
to review your care plan frequently and modify it when necessary.
xxii OVERVIEW OF THE NURSING PROCESS

Elements of the Care Plan

Care planning formats vary from one health care facility to another; For example, you may write
your care plan on a form supplied by the hospital, or you can use software that's approved by
your facility. Nearly all care planning formats include space in which to document the nursing
diagnoses, expected outcomes, and nursing interventions. In many health care facilities, you
may also document assessment data and discharge planning on the care plan.
No matter which format you use, be sure to write the care plan in ink (and sign it), even
though you may have to make revisions if your nursing interventions don't work. Remember-the
patient's care plan becomes part of the permanent record and shouldn't be erased or destroyed.
The information must remain intact, enabling you and other health care team members to readily
refer to nursing interventions used in the past. (See Box 6, Guidelines for Writing a Care Plan.)
Be specific when writing your care plan. By discussing specific problems, expected outcomes,
nursing interventions, and evaluations for expected outcomes, you leave no doubt as to what
needs to be done by other health care team members. For example, when listing nursing inter-
ventions, be sure to include when the action should be implemented, who should be involved
in each aspect of implementation, and the frequency, quantity, and method to be used. Specify
dates and times when appropriate. List target dates for each expected outcome.
If your nursing interventions have resolved the problem on which you've based the nurs-
ing diagnosis, write "discontinued,. next to the diagnostic statement on the care plan, and list
the date you discontinued the interventions. If your nursing interventions haven't resolved the
problem by the target date, reevaluate your plan and do one of the following:
• Extend the target date, and continue the intervention until the patient responds as
expected.
• Discontinue the intervention, and select a new one that will achieve the expected outcome.

BOX 6. GUIDELINES FOR WRITING A CARE PLAN

Keeping these tips in mind will help you write an accurate and useful care plan.
• Write your patient's care plan in ink-it's part of the permanent record. Sign your name.
• Be specific; don't use vague terms or generalities on the care plan.
• Never use abbreviations that may be confused or misinterpreted. In general, it's better to use only established
abbreviations and acronyms.
• Take time to review all your assessment data before you select an approach for each problem. (Note: If you
can't complete the initial assessment, immediately note "insufficient database" on your records.)
• Write down a specific expected outcome for each problem you identify, and record a target date for its completion.
• Avoid setting an initial goal that's too high to be achieved. For example, the outcome for a newly admitted pa-
tient with stroke stating, "Patient will ambulate with assistance," is an unrealistic initial goal because several
patient outcomes will need to be achieved before this goal can be addressed.
• Consider the following three phases of patient care when writing nursing interventions: What observations to
make and how often, what nursing measures to do and how to do them, and what to teach the patient and
family before discharge.
• Make each nursing intervention specific.
• Make sure nursing interventions match the resources and capabilities of the staff. Combine what's necessary
to correct or modify the problem with what's reasonably possible in your setting.
• Be creative when you write your patient's care plan; include a drawing or an innovative procedure if either
will make your directions more specific:.
• Don't overlook any of the patient's problems or concerns. Include them on the care plan so they won't be forgotten.
• Make sure your care plan is implemented correctly.
• Evaluate the results of your care plan, and discontinue any nursing diagnoses that have been resolved. Select
new approaches, if necessary, for problems that haven't been resolved.
 OVERVIEW OF THE NURSING PROCESS xxiii
You'll need to update and modify a patient's care plan as problems (or priorities) change
and resolve, new assessment information becomes available, and you evaluate the patient's
responses to nursing interventions.

IMPLEMENTATION
During this phase, you put your care plan into action. Implementation encompasses all nursing
interventions directed toward solving the patient's nursing problems and meeting health care
needs. While you coordinate implementation, you also seek help from other caregivers, the
patient, and the patient's family. (See Box 7, Understanding NIC.)
Implementation requires some (or all) of the following interventions:
• Assessing and monitoring (e.g., recording vital signs)
• Therapeutic interventions (e.g., giving medications)
• Making the patient more comfortable and helping him with ADLs
• Supporting the patient's respiratory and elimination functions
• Providing skin care
• Managing the environment (e.g., controlling noise to ensure a good night's sleep}
• Providing food and fluids
• Giving emotional support
• Teaching and counseling
• Referring the patient to appropriate agencies or services.
Incorporate these elements into the implementation stage:
• Reassessing: Although it may be brief or narrowly focused, reassessment should confirm
that the planned interventions remain appropriate.
• Reviewing and modifying the care plan: Never static, an appropriate care plan changes
with the patient's condition. As necessary, update the assessment, nursing diagnoses, im-
plementation, and evaluation sections. (Entering the new data in a different color of ink
alerts other staff members to the revisions.) Date the revisions.
• Seeking assistance: Determine, for example, whether you need help from other staff mem-
bers or additional information before you can intervene.

Documentation
Implementation isn't complete until you've documented each intervention, the time it occurred,
the patient's response, and any other pertinent information. Make sure each entry relates to a
nursing diagnosis. Remember that any action not documented may be overlooked during quality
assurance monitoring or evaluation of care. Thorough documentation offers a way for you to
take rightful credit for your contribution in helping a patient achieve the highest possible level

BOX 7. UNDERSTANDING NIC

The Nursing Interventions Classification (NIC) is a research-based clinical tool that standardizes and
defines the knowledge base for nursing practice; it was developed by a nursing research team at the Uni-
versity of Iowa. It contains 554 interventions organized into 30 classes and 7 domains. Each intervention
has a definition, list of indicators, publication facts line, and references (Bulechek, Butcher, Dochterman,
& Wagner, 2013). The interventions are research based, and studies are ongoing to evaluate the effective-
ness and cost of nursing treatments. More information about NIC can be found at the Center for Nursing
Classification and Clinical Effectiveness (www.nursing.uiowa.edu/cnc).
xxiv OVERVIEW OF THE NURSING PROCESS

BOX 8. NURSING INTERVENTIONS: THREE TYPES

Knowing the three types of nursing interventions will help you document implementation appropriately.
• Independent interventions. These interventions fall within the purview of nursing pracfa:e and don't require a
physician's direction or supervision. Most nursing actions required by the patient's care plan are independent
interventions. Examples include patient teaching, health promotion, counseling, and helping the patient with
activities of daily living.
• Dependent interventions. Based on written or oral instructions from another professional-usually a physi-
cian-dependent interventions include administering medication, inserting indwelling urinary catheters, and
obtaining specimens for laboratory tests.
• Interdependent interventions. Performed in collaboration with other professionals, interdependent interven-
tions include following a protocol and carrying out standing orders.

of wellness. After all, nurses use a unique and worthwhile combination of interpersonal, intel-
lectual, and technical skills when providing care. (See Box 8, Nursing Interventions: Three Types.)

Evaluation
In this phase of the nursing process, you assess the effectiveness of the care plan by answering
such questions as:
• How has the patient progressed in terms of the plan's projected outcomes?
• Does the patient have new needs?
• Does the care plan need to be revised?
Evaluation also helps you determine whether the patient received high-quality care from
the nursing staff and the health care facility.

Steps in the Evaluation Process

Include the patient, family members, and other health care professionals in the evaluation.
Then follow these steps:
• Select evaluation criteria: The care plan projected outcomes-the desired effects of nurs-
ing interventions-form the basis for evaluation.
• Compare the patient's response with the evaluation criteria: Did the patient respond as
expected? If not, the care plan may need revision.
• Analyze your findings: If your plan wasn't effective, determine why. You may conclude,
for example, that several nursing diagnoses were inaccurate.
• Modify the care plan: Make revisions (e.g., change inaccurate nursing diagnoses) and
implement the new plan.
• Reevaluate: Like all steps in the nursing process, evaluation is ongoing. Continue to as-
sess, plan, implement, and evaluate for as long as you care for the patient.

Questions to Answer
When evaluating and documenting the patient's care, collect information from all available
sources-for example, the patient's medical record, family members, other caregivers, and the
patient. Include your own observations.
During the evaluation process, ask yourself these questions:
• Has the patient's condition improved, deteriorated, or remained the same?
• Were the nursing diagnoses accurate?
• Have the patient's nursing needs been met?
 OVERVIEW OF THE NURSING PROCESS XXV

• Did the patient meet the outcome criteria documented in the care plan?
• Which nursing interventions should I revise or discontinue?
• Why did the patient fail to meet some goals (if applicable)?
• Should I reorder priorities? Revise expected outcomes.

NURSING DIAGNOSES AND CRITICAL PATHWAYS

In a growing nwnber of health care settings-inpatient and outpatient, acute and long-term
care--critical pathways are being used to guide the process of care for a patient. Critical pathways
describe the course of a specific health-related condition. A critical pathway may be used along
with or instead of a nursing care plan, depending on the standards set by the individual health
care facility. These tools may also be referred to as clinical pathways, care maps, collabora-
tive care plans, or multidisciplinary action plans. (See Box 9, Developing a Critical Pathway.)
The concept of the critical pathway evolved out of the growth of managed care and the
development of the case management model in the early 1990s. Pressure from managed care
organizations to control costs led to the evolution of case management.
In case management, one professional-usually a nurse or a social worker-assumes re-
sponsibility for coordinating care so that patients move through the health care system in the
shortest time and at the lowest cost possible.
Early on, case managers used the nursing process and based their plans on nursing diag-
noses. Over time, however. it became evident that a multidisciplinary approach was needed to
adequately monitor the length of stay and reduce overall costs. This led to the development of
the critical pathway concept.
In critical pathways, a time line is defined for each condition and for the achievement of
expected outcomes. By reading the critical pathway, caregivers can determine on any given day
where the patient should be in his or her progress toward optimal health.

BOX 9. DEVELOPING A CRITICAL PATHWAY

The critical pathway is an interdisciplinary tool that requires the collaborative efforts of all disciplines involved
in patient care. The interdisciplinary team must decide on a diagnosis, select a set of achievable outcomes, and
agree on a plausible time line for achieving the desired outcomes. Note that when establishing standard prac-
tices for treatment of a given condition, it has usually proved difficult for physicians to achieve consensus.
ESTABLISHING A TIME LINE
Time intervals allocated on a critical pathway vary according to the patient's condition and its acuity. For
a hip replacement, the time line extends over days; for a cardiac catheterization procedure, time intervals
are expressed in hours. In the postanesthesia period, a critical pathway can be defined in minutes.
Average length of stay is an important concept in developing a critical pathway. If agency data indicate
that the average length of stay for an inpatient who has had a modified radical mastectomy with recon-
struction is 4 days, then the team begins planning around a 4-day stay.
BUILDING THE PATHWAY
The interdisciplinary team must choose a framework for developing outcomes and interventions. Some
agencies build pathways around nursing diagnoses. If interdisciplinary collaboration is strong, an agency
may build pathways around general aspects of care; for example, pain, activity, nutrition, assessment,
medications, psychosocial status, treatments, teaching, and discharge planning.
In an acute care setting, outcomes and interventions for each aspect of care are determined for each
day of an expected length of stay. In long-term care and other community-based settings, progress may be
measured in longer intervals.
xxvi OVERVIEW OF THE NURSING PROCESS

The critical pathway provides a method for physicians and nurses to standardize and or-
ganize care for routine conditions. These pathways also make it easier for case managers to
track data needed to
• streamline utilization of material resources and labor
• ensure that patients receive quality care
• improve the coordination of care
• reduce the cost of providing care
The most successful critical pathways have been developed for medical diagnoses with
predictable outcomes, such as hip replacement, mastectomy, myocardial infarction, and cardiac
catheterization. Critical pathways work best with high-volume, high-risk, high-cost conditions
or procedures for which there are predictable outcomes.

Care Planning for Students

Developing a care plan helps the nursing student improve problem-solving technique, learn
the nursing process, improve written and verbal communication, and develop organizational
skills. More important, it shows how to apply classroom and textbook knowledge to practice.
Because the purpose is to teach the care planning process, the student care plan is longer
than the standard plan used in most health care facilities. In a step-by-step manner, student
care plans progress from assessment to evaluation. However, some teaching institutions model
the student care plan on the plan used by the affiliated health care institution, adding a space
for the scientific rationale for each nursing intervention selected.
Writing out all of your planned actions enables you to review planned nursing activities
with your clinical instructor. This is an opportunity to consider whether you have complete
assessment data to support your diagnoses and interventions and whether you've taken into
consideration all the problems that a more experienced nurse is likely to identify. See Box 10
for an explanation of each section of a care plan.

The Importance of Nursing Diagnoses

Using a critical pathway can be helpful, especially for nursing students and new graduates. You
may be assigned to provide care to a particular patient for only 1 or 2 days. Seeing the entire
pathway and examining the outcomes the patient is expected to achieve will help you obtain
a broader clinical perspective on care.
Using a critical pathway as a guide for delivering care does not negate the need to formulate
and utilize nursing diagnoses. Nursing diagnoses continue to define the primary responsibility
of nursing-to diagnose and treat human responses to actual or potential health problems.
The full nursing care needs of any patient are unlikely to be documented in a critical pathway.
When using a pathway, always keep in mind that the patient may require nursing intervention
beyond what's specified in the critical pathway.
For example, a patient enters a hospital for a hip replacement and can't communicate ver-
bally because of a recent stroke. The critical pathway wouldn't include measures to assist the
patient to disclose personal needs. Therefore, you would develop a nursing care plan around
the diagnosis "Impaired verbal communication related to decreased circulation to the brain."
Even if you practice in a clinical setting that relies on critical pathways to fill documentation
requirements, the Nursing Diagnosis Reference Manual, tenth edition, will prove to be a valu-
able resource for identifying and treating each patient's unique nursing needs. Creating a care
plan based on carefully selected nursing diagnoses and using it along with a critical pathway
will enable you to provide your patients with high-quality collaborative care that includes a
strong nursing component.
 OVERVIEW OF THE NURSING PROCESS xxvii

BOX 10. CARE PLANS

All care plans contain the following sections:

• Diagnostic s'tatement. Each diagnostic statement indudes a NANDA-I-approved diagnosis and, in most cases,
a related etiology. This edition of the Nursing Diagnosis Reference Manual contains all the diagnoses ap-
proved by NANDA-I to date.
• Definition. This section offers a brief explanation of the diagnosis.
• Assessment. This section suggests parameters to use when collecting data to ensure an accurate diagnosis.
Data may include health history, physical findings, psychosocial status, laboratory studies, patient statements,
and other subjective and objective information.
• Defining characteristics. This section lists dinical findings that confirm the diagnosis. For diagnoses expressing
the possibility of a problem, such as "Risk for injury," this section is labeled Risk factors.
• Expected outcomes. Here you'll find realistic goals for resolving or ameliorating the patient's health problem,
written in measurable behavioral terms. You should select outcomes that are appropriate to the condition of
your patient. Outcomes are arranged to flow logically from admission to discharge of the patient. Outcomes
identified by NOC research have been added to correlate with the NANDA-I expected outcomes.
• Interventions and rationales. This section provides specific activities you carry out to help attain expected
outcomes. Each intervention contains a rationale, highlighted in italic type. Rationales receive typographic
emphasis because they form the premise for every nursing action. You'll find it helpful to consider rationales
before intervening. Understanding the why of your actions can help you see that carrying out repetitive or dif-
ficult interventions is an essential element of your nursing practice. More importantly, it can improve critical
thinking and help you to avoid mistakes. Interventions from NIC research have been added to correlate with
the interventions.
• Evaluations for expected outcomes. Here you'll find evaluation criteria for the expected outcomes. These cri-
teria will help you determine whether expected outcomes have been attained or provide support for revising
outcomes or interventions to meet changing patient conditions.
• Documentation. This section lists critical topics to indude in your documentation-for example, patient per-
ceptions, status, and response to treatment as well as nursing observations and interventions. Using the infor-
mation provided in this section will enable you to write the careful, concise documentation required to meet
professional nursing standards.

REFERENCES
American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring,
MD: Author.
Herdman, T. H. & Kamitsuru, S. (Eds.). (2014). NANDA International, Inc. nursing diagnoses: Defini-
tions and classification, 2015-2017 (10th ed.). Oxford: Wiley-Blackwell.
 Adult Health

- APPLYING EVIDENCE-BASED PRACTICE

The Question
Does weight cycling (yo-yo dieting) have any long-term adverse health effects?

Evidence-B•sed Resources
Bosy-Westphal, A., KahlhOfer, J., Lagerpusch, M., Skurk, T., & MUller; M. J. (2015). Deep
body composition phenotyping during weight ~ling: Relevance to metabolic efficiency
and metabolic risk. Obesity Reviews, 16, 36-44. d.oi:10.111Uobr.12254
Bosy-Weatphal, A., & MUlltt, M. J. (2014). Measuring the impact of weight cycling on body
composition: A methodological challenge. Currmt Opinion in Clin~l Nutrition & Meta-
bolic Care, l 7(5), 3.96-400. d.oi:l0.10.97/MC0.00000000000000.92
Delahanty, L. M., P~ Q., Jablonski, K. A., Aroda, V. R., Watson, K. E., Bray, G. A., ... Franks,
P. W. (2014 ). Effects of weight loss, weight~. and weight loss maintenance on diabms
incidence and change in cardiometabolic: traits in the diabm:s prevention program. Diabetes
Care, 37(10), 2738-2745. doi:10.2337/dc14-0018
Guth, E. (2014).JAMA patient page. Healthy weight loss.JAMA, 312(9), .974. doi:l0.1001/
jama.2014.10.92.9
Messier; L., Elisha, B., Schmitz, N., Gariepy, G., Malla, A., Lesage, A., ... Strychar, I. (2014).
Weight cycling and depressive symptoms in diabetes: A community-based study of adults
with type 2 diabetes mellitus in Quebec. <Anadian Journal of Diabetes, 38(6), 456-460.
d.oi:10.1016/j .jcjd.2014.01.005
Montani, J. P., Schutz, Y., & Dulloo, A. G. (2015). Dieting and weight cycling as risk factors
for cardiometabolic diseases: who is really at risk? Obesity Reviews, 16, 7-18. doi: 10.111 U
obr.12251
Murphy, R. A., Patd, K. V., Kritchcvsky, S. B., Houston, D. K., Newman, A. B., Koster; A., ...
Harris, T. B. (2014). Weight change, body composition, and rislc of mobility disability and
mortality in older adults: A population-based cohort study. ]OUN141 of the American Geri-
atrics Society, 62(8), 147~1483. doi:l0.1111/jgs.12954

1
Stevens, V. L., Jacobs, E. J., Patel, A. V., Juzhong, S., McCullough, M. L., Campbell, P. T., &
Gapstur, S. M. (2015). Weight cycling and cancer incidence in a large prospective U.S. cohort.
American Journal of Epidemiology, 182(5), 394-404. doi:10.1093/ajdkwv073

Evaluating the Evidence

Almost half of all adults in the United States have attempted to lose weight. Many of these
individuals try diet after diet to lose extra pounds only to gain them back, creating a vicious
cycle of weight loss and gain. This type of dieting is called yo-yo dieting or cycling (Stevens
et al., 2015). Because many individuals try to lose weight, it is important to investigate whether
this method of dieting has any long-term adverse effects.
Multiple studies (Bosy-Westphal, Kahlhofer, Lagerpusch, Skurk, & Muller, 2015; Bosy-
Westphal & Muller, 2014; Delahanty et al., 2014; Messier et al., 2014; Montani, Schutz, &
Dulloo, 2015; Stevens et al., 2015) have explored the relationship between weight cycling and
increased risk for adverse health effects. Unfortunately, there isn't a clear or unanimous conclu-
sion on whether weight fluctuation is related to development of disease or illness. Although
most studies conclude there is no overall increased risk of adverse health effects, specifically
from weight cycling, there may be increased risks for certain individuals and conditions.
Two diseases in which obesity is a risk factor are diabetes and cancer. Overweight individuals
considered at risk for either of these diseases are often told to lose weight. A study by Delahanty
et al. (2014) examined the relationship between weight cycling and incidence of diabetes. The
study's results indicated an association with increased risk of hypertension and diabetes. Messier
ct al. (2014) examined the effects of weight cycling by patients already diagnosed with type 2
diabetes. The results concluded there are no increased associated risks in diabetic patients. In
turn, Stevens et al. (2015) investigated whether weight cycling increased cancer risk and found
no evidence to indicate any overall increased risks.
Another concern associated with weight cycling is that the body may gain too much fat in
comparison with lean muscle mass or there will be a negative impact on body fat distribution.
Two studies (Bosy-Westphal et al., 2015; Bosy-Westphal & Miiller, 2014) investigated the ef-
fects of weight cycling on body mass. Although both studies indicate there is no evidence of
overall adverse effects on body composition when weight cycling, Bosy-Westphal & Miiller
(2014) warn that dieters with a starting weight within normal limits may experience adverse
effects. Evidence indicates that severe weight loss in individuals who are considered within
normal weight range may regain a higher amount of abdominal fat mass.
Although some studies in the past have associated weight cycling with mortality, many
didn't differentiate weight cycling that is initiated by intentional weight loss from that initi-
ated by illness. One recent study explored the differences. Murphy et al. (2014) found that
in older adults (aged 70 to 79), there is a possible relationship between unintentional weight
change and a higher risk of mortality. However, results from this study indicated that there is
no relationship between intentional weight change and the risk of mortality.
In conclusion, although study results are divided on the risks, there is evidence that sug-
gests weight cycling does not have overall negative effects on health. These findings may be
significant because estimates indicate that nearly half of Americans have yo-yo dieted while
attempting to lose weight.

Applying the Results and Making a Decision

Maintaining a stable weight over time is definitely the best practice. However, overweight
people should not stop exercising and trying to lose weight just because they have a history
of cycling. Studies have shown that cycling can be beneficial when attempting to lose weight.
Because there is no associated overall increased risk for adverse health effects, overweight and
obese individuals should be encouraged to attempt weight loss even if the weight will eventu-
ally be regained (Stevens et al., 2015).

Reevaluating Process and Identifying Areas for Improvement

A history of unsuccessful weight loss should not dissuade an individual from future attempts
to shed pounds, nor should it diminish the role of a healthy diet and regular physical activity.
Eating healthy foods and participating in routine physical activity has shown the best results
for maintaining a stable weight (Guth, 2014). Those who practice yo-yo dieting should not
give up, and if they gain back the weight, there is evidence that losing it again will not be
detrimental to their health.
4 PART I -ADULT HEALTH

INTRODUCTION _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

This section includes approximately 200 alphabetically organized diagnostic labels and associ-
aml. care plans that identify adult health problems responsive to independent nursing action.
Many focus on meeting the patient's actual physiologic needs. For example, you'll find care
plans that will assist you to plan the care of a patient with decreased cardiac output, help
an injured patient maintain joint range of motion, and teach an immwiosuppressed patient
measures to prevent infection. In addition, you'll find plans for warding off potential health
problems, such as risk for infection or injury.
Other care plans focus on the psychological and psychosocial problems of adulthood. For
example, if a patient with a chronic illness experiences related emotional difficulties, such
diagnostic labels as hopelessness, ineffective role performance, and disturbed body image
ma.y help pinpoint the patient's needs. If a patient lacks adequate financial, social, or spiritual
resources, appropriate care plans provide instructions for documenting such hardships and
interventions for ameliorating them.
Still other care plans focus on more specialized patient problems. For example, you'll find
plans for patients widergoing surgery.
In summary, the diagnostic labels and associated care plans covered in this section encom-
pass the full range of nursing responsibilities. To make full use of this broad database, you'll
need to perform a complete and careful nursing assessment. When appropriate, include ques-
tions about the patient's cultural background. Ask about self-concept, stressors, daily living
habits, and coping mechanisms. Discuss the patient's health goals. How well does the patient
widerstand his or her condition? Will family members or friends take an active role in patient
care? Your assessment should also include infonnation derived from your own observations.
Use information gathered during assessment to select an accurate diagnostic statement
and an appropriate care plan. That way, you can ensure your adult patient comprehensive,
individualized, and consistent nursing care.

- ACTIVITY INTOLERANCE
related to Imbalance between oxygen supply and demand

Definition
Insufficient physiologic or psychological energy to endure or complete required or desired
daily activities

Assessment
• History of circulatory disease, respiratory disease, or both
• Patient's perception of tolerance for activity
• Current medications, effectiveness
• Respiratory status, including pulse oximetry; pulmonary function studies; and respiratory
rate, depth, and pattern at rest and with activity
• Cardiovascular status, including blood pressure, complere blood count, stress electrocar-
diogram (ECG) results, and heart rate and rhythm at rest and with activity
• Knowledge, including understanding of present condition; perception of need to maintain
or restore an activity level consistent with capabilities; and physical, mental, and emo·
tional readiness to learn
 Activity Intolerance 5

Defining Charaderistics
• Abnormal blood pressure response to activity
• Abnormal heart rate response to activity
• ECG change (e.g., arrhythmia, conduction abnormality, ischemia)
• Exertional discomfort
• Exertional dyspnea
• Fatigue
• Generalized weakness

Expeded Outcomes
• Patient will state desire to increase activity level.
• Patient will state understanding of the need to increase activity level gradually.
• Patient will identify controllable factors that cause fatigue.
• Patient's blood pressure and pulse and respiratory rates will remain within prescribed
limits during activity.
• Patient will state a sense of satisfaction with each new level of activity attained.
• Patient will demonstrate skill in conserving energy while carrying out daily activities to
tolerance level.
• Patient will explain illness and connect symptoms of activity intolerance with deficit in
oxygen supply or use.

Suggested NOC Outcomes

Activity Tolerance; Discharge Readiness; Endurance; Energy Conservation; Psychomotor

Energy; Self-Care: Activities of Daily Living (AD Ls); Self-Care: Instrumental Activities of
Daily Living (IADLs)

Interventions and Rationales

• Discuss with patient the need for activity. Lack of activity causes physical deconditioning
and may also have a negative impact on psychological well-being.
l:l'D • Identify activities the patient considers desirable and meaningful. Engaging patient in ac-
tivities that have personal meaning gives the patient a greater sense of independence and
may motivate patient to continue developing tolerance.
• Encourage patient to help plan activity progression, being sure to include activities the
patient considers essential. Participation in planning may encourage patient compliance
with the plan.
• Instruct and help patient to alternate periods of rest and activity. Providing rest periods
prevents fatigue and encourages patient to continue improving activity tolerance.
• Remove barriers that prevent patient from achieving goals that have been established to
minimize factors that may decrease patient's exercise tolerance.
. . • Monitor physiologic responses to increased activity (including respirations, pulse oxim-
etry, heart rate and rhythm, and blood pressure). Document the time after each period
of exercise. Wait 5 minutes and measure physiologic responses. Values should return to
normal within 5 minutes or less.
l:l'D • Teach patient how to conserve energy while performing ADLs-for example, sitting in a
chair while dressing, wearing lightweight clothing that fastens with Velcro or a few large
buttons, and wearing slip-on shoes. These measures reduce cellular metabolism and oxy-
gen demand.
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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