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Library of Congress Cataloging-in-Publication Data
LeMone, Priscilla, author.

Medical-surgical nursing : clinical reasoning in patient care/Priscilla LeMone, Karen Burke,
Gerene Bauldoff, Paula Gubrud.—Sixth edition.
p.; cm.
Includes bibliographical references.
ISBN-13: 978-0-13-313943-3
ISBN-10: 0-13-313943-3
I. Burke, Karen M., author. II. Bauldoff, Gerene, author. III. Gubrud-Howe, Paula Marie, author. IV. Title.
[DNLM: 1. Nursing Process. 2. Nursing Care. 3. Patient Care Planning. 4. Perioperative Nursing. WY 100.1]RT41
R728.8.B425 2011
617′.0231—dc23
2014004072
10 9 8 7 6 5 4 3 2 1
ISBN-13: 978-0-13-313943-3
ISBN-10: 0-13-313943-3
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About the Authors
Priscilla LeMone-Koeplin, RN, Reflecting her passion for nursing and education, Ms. Burke
DSN, FAAN currently serves on boards of directors for Supporters of Oregon
Associate Professor Emeritus, Sinclair Consortium for Nursing Education (OCNE), Clatsop Community
School of Nursing, University of Missouri. College, and Clatsop Care Center Health District. She enjoys gar-
Priscilla LeMone-Koeplin spent most dening and is a member of the Clatsop County Master Gardener
of her career as a nurse educator, teach- Association. Her other interests include family, quilting, and fishing.
ing medical-surgical nursing and patho-
physiology at all levels from diploma I dedicate this book to the leaders and visionaries who provide direction
to doctoral students. She has a diploma for the future of nursing—and to all the nursing students who will carry
in nursing from Deaconess College of our profession into that future and beyond.
Nursing (St. Louis, Missouri), baccalaure- Karen Burke
ate and master’s degrees from Southeast Missouri State University, and
a doctorate in nursing from the University of Alabama–Birmingham. Gerene Bauldoff, RN,
Dr. LeMone-Koeplin has received numerous awards for scholar- PhD, FAAN
ship and teaching, including the Kemper Fellowship for Teaching Gerene Bauldoff is a Professor of Clinical
Excellence from the University of Missouri, the Unique Contribution Nursing at The Ohio State University
Award from the North American Nursing Diagnosis Association, College of Nursing in Columbus, Ohio.
and being selected as a Fellow in the American Academy of Nursing. She has been a nurse educator for 14 years,
Dr. LeMone-Koeplin currently lives in Ohio. She enjoys traveling, teaching medical-surgical nursing, trans-
gardening, knitting, and reading fiction. lational science, and evidence-based prac-
tice courses at the baccalaureate, master’s,
I dedicate this book to all the students who will become the caregivers. and doctoral levels. Prior to her nursing
How far you go in life depends on your being tender with the young, educator role, her clinical background
compassionate with the aged, sympathetic with the striving and tolerant included home health nurse, lung transplant coordinator, and pul-
of the weak and the strong, because someday in your life you will have monary rehabilitation coordinator. Dr. Bauldoff has a diploma from
been all of these. (George Washington Carver) the Western Pennsylvania Hospital School of Nursing, Pittsburgh,
Priscilla LeMone-Koeplin Pennsylvania, and a BSN from LaRoche College in Pittsburgh. Her
graduate education is from the University of Pittsburgh, with a MSN
Karen M. Burke, RN, MS in medical-surgical nursing (cardiopulmonary clinical nurse special-
Karen Burke began her nursing career ist) and PhD in nursing in 2001, training under Leslie Hoffman, PhD,
working in cardiac and intensive care, RN, FAAN.
moving from there into nursing educa- Dr. Bauldoff is an active member of multiple professional
tion, and then nursing education program organizations including the American Academy of Nursing
management with the Board of Nursing. (AAN), Sigma Theta Tau International Honor Society of Nursing,
She currently serves as a consultant for the American Association of Cardiovascular and Pulmonary
nursing education programs. Rehabilitation (AACVPR), the American Thoracic Society Nursing
Ms. Burke earned her diploma in Assembly, and the American College of Chest Physicians (ACCP).
nursing from Emanuel Hospital School She is a recognized expert in medical-surgical nursing, focusing
of Nursing in Portland, Oregon, later on the care of the patient with chronic pulmonary disease, serv-
completing baccalaureate studies at Oregon Health & Science ing on committees focusing on patient-centered outcomes in pul-
University, and a master’s degree in nursing at the University of monary rehabilitation. She has been honored with fellowships in
Portland. She has been actively involved in nursing education and AAN, AACVPR, and ACCP. In 2013, Dr. Bauldoff was the keynote
clinical nursing education reform. Ms. Burke is coauthor of another speaker at the Nanning Nursing Education Conference in Nanning,
text, Medical-Surgical Nursing Care (4th edition) with Elaine China, attended by representatives from more than 100 nursing
Mohn-Brown and Linda Eby. Ms. Burke strongly values the nursing schools in China.
profession and the importance of providing a strong education in the Dr. Bauldoff views nursing as the greatest profession, using sci-
art and science of nursing for students preparing to enter the profes- entific evidence to provide the highest quality of care while maintain-
sion, no matter which educational path is being pursued. ing the personal relationship with patients and their families. Her
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iv About the Authors
experiences provide her with insights and lessons learned that she c ommunity colleges. She also has more than 20 years of experience
shares with her students. in medical-surgical nursing, critical care, home health, and hospice.
Dr. Bauldoff resides in central Ohio. She enjoys travelling, walk- Dr. Gubrud-Howe earned a baccalaureate degree in nursing from
ing, bicycling, golf, and spending time with her family and friends. Walla Walla University (1980), a MS in community-based nursing
from OHSU (1993), and an EdD in postsecondary education from
I dedicate this book to the memory of my parents and to my sisters, Corita Portland State University (2008). She is a frequent invited speaker
Bauldoff, Jilana Alfonso, and Michelle Ciliberto—you are my touchstones at national and international nursing education conferences and
to the real world and are my greatest cheerleaders. You help me keep my consults with other states and countries on the development of
feet on the ground and my face turned toward new opportunities. I love competency-based curriculum and nursing education consortiums
you and thank you! designed to promote academic progression in nursing education.
Gerene Bauldoff Her research activity is focused on clinical education redesign and
the integration of simulation into nursing curriculum.
Paula Gubrud-Howe, RN, Dr. Gubrud-Howe is passionate about nursing and the oppor-
MS, EdD., FAAN tunities it provides members of the profession. She values the sacred
Paula Gubrud-Howe is Senior relationship nurses experience with patients as they promote health,
Associate Dean for Academic Affairs treat illness, and provide comfort and palliative care. She believes
and an Associate Professor at Oregon the nation’s health depends on highly qualified nurses who are
Health and Science University dedicated to lifelong learning in pursuit of evidence-based, patient-
(OHSU) School of Nursing. She has centered care.
more than 25 years of experience as
a nurse educator involving multiple I dedicate this book to my husband Leland Howe and my children
levels of programs from LPN to doc- Elizabeth Gubrud-Howe, Gabriel Howe, and Caleb Howe for encouraging
toral education. Dr. Gubrud-Howe me to pursue my professional passions and goals. I also dedicate this
is a founding leader and co-director book to my father, Allan Gubrud, who instilled insatiable curiosity, a love
of the Oregon Consortium for Nursing Education, an award win- of learning, and a passion to teach.
ning consortium that includes the five campuses of OHSU and nine Paula Gubrud Howe
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Thank You
Contributors
We extend a heartfelt thanks to our contributors, who gave their time, effort, and expertise so
tirelessly to the development and writing of chapters and resources that helped foster our goal
of preparing student nurses for evidence-based practice.
Jane Bostick, RN, PhD Kimberly Regis, RN, DNP, PNP-BC Victoria von Sadovszky, PhD, RN
University of Missouri–Columbia Nationwide Children’s Hospital Associate Professor
Columbia, Missouri Ambulatory Specialty Clinics Director, Undergraduate Honors Program
Chapter 6 Columbus, Ohio The Ohio State University College
Mei R. Fu, PhD, RN, ACNS-BC, FAAN Chapter 8 of Nursing
Associate Professor Donna Russo, RN, MSN, CCRN, CNE Columbus, Ohio
College of Nursing Nursing Instructor Chapter 50
New York University ARIA Health School of Nursing Janice Wilcox, MSN, RN
New York, New York Trevose, Pennsylvania Nurse Educator/Clinical Instructor
Chapter 14 End of Unit feature James Nursing Staff Development
Dawna Martich, MSN, RN Carolyn Schubert, DNP, RN, BC The Ohio State University College
of Nursing
Nursing Education Consultant Clinical Assistant Professor
Columbus, Ohio
Pittsburgh, Pennsylvania The Ohio State University College of
Nursing Chapters 47, 48, and 49
Test Yourself NCLEX Review
Columbus, Ohio Rebecca Yee Bassett, MS, CGC
JoAnne M. Pearce, MS RN
Chapters 43 and 44 Board Certified Genetic Counselor
Assistant Professor
Betsy Swinny MSN, RN, CCRN NYU Clinical Cancer Center
Director of Nursing of Programs
Faculty III New York, New York
College of Technology
Baptist Health System, School of Health Chapter 14
Idaho State University
Pocatello, Idaho Professions
Chapter 4 San Antonio, Texas
Chapters 18, 19, and 20
Reviewers
Our heartfelt thanks go to our colleagues from schools of nursing across the country who have
given generously of their time to help create this exciting new edition of our medical-surgical nurs-
ing textbook. These individuals helped us plan and shape our book and resources by reviewing
chapters, art, design, and more. Medical-Surgical Nursing: Clinical Reasoning in Patient Care
has reaped the benefit of your collective knowledge and experience as nurses and teachers, and
we have improved the materials due to your efforts, suggestions, objections, endorsements, and
inspiration. Among those who gave their time to help us are the following:
Wanda G. Barlow, MSN, RN, FNP-BC Judith Faust, MSN, RN, CNE Catherine Howell, RN, MSN
Nursing Instructor Associate Professor Professor, Nursing Education
Winston Salem University Ivy Tech Community College San Diego City College
Winston Salem, North Carolina Lafayette, Indiana San Diego, California
Angie Brindowski, MSN, BSN, RN Jacqueline Guhde, MSN, RN, CNS Noreen C. Kostelecky, MSN, RN
Department Chair Senior Instructor Peoria, Illinois
Clinical Assistant Professor The University of Akron Lynda S. Logan, MSN, RN
Carroll University Akron, Ohio Assistant Professor, School of Nursing
Waukesha, Wisconsin Shawna Harvey, MSN, RN Ivy Tech Community College
Deborah Ellis, RN, MSN, FNP Dean of Nursing Lafayette, Indiana
Associate Professor of Nursing Fortis College, Westerville
Missouri Western State University Newark, Ohio
St. Joseph, Missouri
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vi Thank You
Heidi Loucks, MS, RN, CNE Mary Elizabeth McKenna-Dailey, Laree J. Schoolmeesters, PhD,
Nurse Educator FNP-BC RN, CNL
Casper College Professor, Nurse Education Associate Professor
Casper, Wyoming North Shore Community College Queens University of Charlotte
Naomi Lungstrom, MN, ARNP, FNP Danvers, Massachusetts Presbyterian School of Nursing
Clinical Assistant Professor Nancy Peifer Neil, RN, BSN, MSN, PhD Charlotte, North Carolina
Washington State University Palm Beach State College Marianne Swihart, MEd, MSN,
Spokane, Washington Lake Worth, Florida BSN, AS
Sonia Rudolph, RN, MSN, APRN, Associate Professor
Andrea R. Mann, MSN, RN, CNE
FNP-BC Pasco Hernando Community College
Third Level Chair and Instructor
Nursing Division Chair New Port Richey, Florida
Aria Health School of Nursing
Trevose, Pennsylvania Jefferson Community & Technical College
Louisville, Kentucky
Greta I. Marek, DNP, RN, CNE
Assistant Professor Donna Russo, RN, MSN, CCRN, CNE
East Tennessee State University Nursing Instructor
College of Nursing ARIA Health School of Nursing
Johnson City, Tennessee Trevose, Pennsylvania
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Preface
Why We Wrote This Book ple learning strategies to facilitate success—audio, illustrations, teach-
Dr. LeMone-Koeplin developed the original vision for Medical-Surgical ing tips, and video and animation media.
Nursing: Clinical Reasoning in Patient Care based on the belief that Starting with the first edition, we have held fast to our vision that
nursing is a holistic, evidence-based, person-centered profession. this textbook:
Nursing care, therefore, is provided for the whole person, not just for • Maintains a strong focus on nursing care as the essential element
a malfunction of one or more body systems. in learning and doing nursing, regardless of the gender, age, race,
The revisions and updates reflected in the sixth edition of culture, or socioeconomic background of the patient or the set-
Medical-Surgical Nursing: Clinical Reasoning in Patient Care further ting for care.
reflect our belief that nurses should possess the necessary knowl- • Provides a balance of pathophysiology, pharmacology, and in-
edge, skills, and attitudes to continuously improve the quality and terprofessional care to support interdependent and independent
safety of care in healthcare systems. We believe that nurses need to nursing interventions.
be able to use evidence-based practice, apply clinical reasoning skills, • Emphasizes the nurse’s role as a caregiver, educator, advocate,
and understand nursing care standards to safely perform complex leader and manager, and as an essential member of the interpro-
skills and tasks. Unit I, Dimensions of Medical-Surgical Nursing, has fessional healthcare team.
been extensively revised to reflect this belief, with expanded discus- • Uses functional health patterns and the nursing process as the
sions of clinical reasoning, essential nursing competencies for prac- structure for providing nursing care in today’s world by prioritiz-
tice (including QSEN competencies), and a new chapter focused on ing nursing diagnoses and interventions specific to altered re-
evidence-based practice and informatics in nursing. sponses to illness.
In this textbook, discussions of the human responses to ill- • Fosters clinical reasoning and decision making as the basis for
ness and disease are structured within the framework of clini- safe, knowledgeable, individualized clinical practice.
cal reasoning and the nursing process. Nursing care is presented
within the context of nursing problems or diagnoses, emphasizing Pearson is pleased to offer a complete suite of resources to sup-
the importance of developing individualized evidence-based plans port teaching and learning, including:
of care. The quality and safety implications for nursing care are • TestGen Test Bank
addressed. Throughout the text, nursing care planning is based • Lecture Note PowerPoints
on a philosophy that individuals, their families, and communities • Classroom Response System PowerPoints
are active participants in health and illness as well as consumers of • New! Annotated Instructor’s eText—This version of the eText is
healthcare services. designed to help instructors maximize their time and resources
Regardless of the type of healthcare service or setting, medical- in preparing for class. The AIE contains suggestions for class-
surgical nurses must use knowledge and skills to provide competent room and clinical activities and key concepts to integrate into the
and safe patient care. The ability to effectively prioritize activities classroom in any way imaginable. Additionally, each chapter has
and patient care needs is critical. Nursing care is structured by the recommendations for integrating other digital Pearson Nursing
activities planned and carried out through clinical reasoning and uses resources, including The Neighborhood 2.0, skills videos, and
multiple thinking strategies when applying the nursing process. Care MyNursingLab.
of the medical-surgical patient is based on established professional
ethics and standards, and is focused on promoting or returning the
patient to a state of functional health or providing palliative care at Organization
the end of life. The 50 chapters in this text are organized into units based on altera-
Throughout the text, we make every effort to communicate that tions in human structure and function. To increase student learn-
both nurses and patients may be male or female; and that patients ing, each chapter in the book includes key terms, learning outcomes
require holistic, individualized care regardless of their age, gender, and clinical competencies, major concepts, chapter highlights, test
or racial, cultural, or socioeconomic background. Our goal is to help yourself NCLEX-type questions, and a bibliography that provides
students acquire the knowledge, resources, and competencies that additional reading.
ensure a solid base for clinical reasoning and that can be applied to Each unit with a focus on altered health opens with an assess-
provide safe, individualized, and competent nursing care. We use ment chapter. This chapter draws on the student’s prerequisite
understandable language and a consistent format, focusing on the knowledge, and serves to reinforce basic principles of anatomy
most commonly encountered conditions. We have developed multi- and physiology as applied to assessment in both health and illness.
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viii Preface
Following the assessment chapter, nursing care chapters provide comprehension of the chapter content. (The correct answers with
information about major illnesses and traumatic injuries. Each rationales are found in Appendix B.)
nursing care chapter follows a consistent format, including three
key components: What’s New in the Sixth Edition
• We are delighted to welcome Paula Gubrud-Howe as a coauthor
Pathophysiology The discussion of each major illness or of this book. Information about Dr. Gubrud-Howe is included in
injury begins with incidence and prevalence, risk factors, and an About the Authors on page iv.
overview of pathophysiology, followed by manifestations (signs and
All the chapters of the sixth edition of this book were extensively
symptoms) and complications. Selected Focus on Cultural Diversity
reviewed, and reviewer comments were used to make this revision.
boxes demonstrate how race, age, and gender affect differences in
New features of the sixth edition include the following:
incidence, prevalence, and mortality.
• Chapter 1, Medical-Surgical Nursing in the 21st Century, includes a
Interprofessional Care Interprofessional care considers significantly expanded discussion of clinical reasoning and Qual-
diagnosis and treatment by the healthcare team. The section ity and Safety Education for Nurses (QSEN) competencies.
includes information, as appropriate, about specific tests necessary • Chapter 2, Informatics and Evidence-Based Practice in Medical-
for diagnosis, medications, surgery and other treatments, fluid Surgical Nursing, is totally new, reflecting our belief that students
management, dietary management, and complementary and need a strong foundation in nursing research, evidence-based
alternative therapies. Specific information with related nursing care practice, and use of informatics and technology in health care.
is highlighted in Medication Administration boxes and Nursing Care of • Clinical Competencies at the beginning of each chapter have been
Patients (such as those having a specific treatment or surgery) boxes. revised to clearly reflect QSEN competencies.
• Three to five Major Chapter Concepts are identified at the begin-
Nursing Care Because illness prevention is critical in healthcare ning of each chapter to assist students in focusing their reading
today, health promotion information introduces the nursing care and study of the chapter by helping pull out key themes or unify-
discussion of major illnesses or injuries. Discussions of selected major ing concepts.
illnesses also include Evidence for Nursing Care boxes with resources • Additional clinical reasoning questions identified as Moving
for additional review in applying evidence to practice. Knowledge into Action appear throughout the book to provide stu-
We discuss nursing assessment and care within a context of dents with opportunities to reflect on and apply their learning to
priorities of care, diagnoses, outcomes, and interventions, with patient care situations.
rationales provided for each intervention. Boxes throughout each • Recognizing the overwhelming number and variety of medica-
illness discussion section present information essential to patient tions nurses must safely administer, the most commonly prescribed
care. These features include Nursing Care, Nursing Care of the Older drugs are italicized throughout this book.
Adult, Meeting Individualized Needs, Practice Alerts, Safety Alerts, • Within nursing care sections for major disorders, three new fea-
and Moving Evidence into Action (a summary of a nursing study with tures have been added:
clinical reasoning questions). • Priorities of Care help the student prioritize care, particularly in
Last, for 80 major disorders or types of trauma, we provide a acute situations.
narrative Case Study & Nursing Care Plan. Clinical reasoning ques- • Expected Outcomes appear after every nursing diagnosis
tions specific to the care plan are provided in a section called Clinical to help the student identify the goal of planned nursing
Reasoning in Patient Care (with suggestions for decision-making interventions.
provided under Evaluating Your Response in Appendix B). The • A Delegating Nursing Care Activities feature has been added to
nursing care section ends with information about continuity of care assist the student in identifying those nursing care activities that
with essential patient and caregiver education, and suggestions for may appropriately be assigned or delegated to assistive personnel.
referrals and additional patient resources. • Continuity of Care replaces the section previously titled Community-
Based Care. This section focuses on the nurse’s responsibility for
Chapter Review This end-of-chapter section concludes preparing the patient and caregivers for transitions of care from one
®
with 10 or more NCLEX-RN -style review questions to reinforce healthcare setting to another or to the home.
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Features
Meeting Individualized Needs Meeting Individualized Needs
Assessing Intimate Partner Violence (IPV) This feature provides essential guidelines for
Most IPV incidents are not reported, thus it is believed that the available neglect, or financial exploitation. In addition, willful deprivation of food providing nursing care to special populations.
data greatly underestimate the true magnitude of the problem. In 2005, or medical care is included. Persons 80 years of age and older expe-
it was reported that 329 males and 1181 females were murdered by rienced abuse and neglect at a rate of two to three times their propor-
an intimate partner. It is estimated that between 1 to 33 million women tion of the older population. The perpetrator is a family member in
(many millions go unreported) are beaten by their intimate partner ev- 90% of the cases (National Center on Elder Abuse, 2013).
ery year, resulting in 2 million injuries. Women make up about 84% The general approach to diagnosis in abuse situations is chal-
of domestic violence victims. One out of every 6 American women lenging and many times hidden. As with spousal, older adult, or child
has been a victim of an attempted or completed rape in her lifetime. abuse, the task of identification is complex. The following are clues to
Among men, 2.78 million have been victims of sexual assault or rape. identify violence-related injuries:
IPV is the single largest cause of injury to women in the United States. • Injuries that do not correlate with the history
This is a widespread problem that occurs regardless of age, sex, race, • Injuries that suggest a defensive posture
socioeconomic status, or education. IPV is also referred to as partner • Injuries during pregnancy
abuse or spousal abuse (CDC, 2012). In 2009, intimate partner vio- • Pattern injuries
lence made up 20% of violent crime against women. The same year, • Pattern burns
intimate partners committed 3% of all violent crimes against men. • Sexual abuse/rape
The United Nations Development Fund for Women estimates that • Unusual or unexplained fractures
at least one of every three women globally will be beaten, raped, or • Signs of confinement
otherwise abused during her lifetime. In most cases, the abuser is a • Unusual interaction between patient and caregiver
member of her own family (Futures without Violence, 2011). • Lack of medical attention; immunizations not up to date, poor
dental health
VIOLENCE IN OLDER ADULTS • Unexplained dehydration or malnutrition.
Elder abuse is defined as anything that endangers the life of an older
adult. This can range from physical or emotional assault to intimidation,
MULTISYSTEM EFFECTS OF
Multisystem Effects Fluid Volume Deficit
An illustrated feature that focuses on the specific disorder,
with manifestations and effects on body systems.
Neurologic
• Altered mental status
• Anxiety, restlessness
• Diminished alertness/cognition
Mucous Membranes • Possible coma (severe FVD)
• Dry; may be sticky
• tongue size,
longitudinal furrows
Integumentary
• Diminished skin turgor
• Dry skin
• Pale, cool extremities
Urinary
Cardiovascular
• urine output
• Tachycardia
• Oliguria (severe FVD)
• Orthostatic hypotension
• urine specific gravity
(moderate FVD)
• Falling systolic/diastolic pressure
(severe FVD)
• Flat neck veins
• venous filling
• pulse volume
• capillary refill
• hematocrit
Potential Complication
• Hypovolemic shock
Musculoskeletal Metabolic Processes

• Fatigue • body temperature
(isotonic FVD)
• body temperature
(dehydration)
• Thirst
• Weight loss
2–4% mild FVD
5–7% moderate FVD
$8% severe FVD
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PATHOPHYSIOLOGY ILLUSTRATED
PATHOPHYSIOLOGY ILLUSTRATED
Throughout, Pathophysiology Illustrated
Cirrhosis and Portal Hypertension
and Multisystem Effects of Illness art brings
changes in physiologic processes to life,
Central vein
helping the student develop a visual memory
Plate of
Normal liver hepatocytes of the disorder and its effects.
Sinusoid
The liver contains multiple
lobules made up of plates of
hepatocytes, the functional
cells of the liver, surrounded by
small capillaries called
sinusoids. These sinusoids
receive a mixture of venous
and arterial blood from
branches of the portal vein and
hepatic artery. Blood from the
sinusoids drains into the
central vein of the lobule. Bile duct
Hepatocytes produce bile, Portal Triad Branch of the portal vein
which drains outward to Branch of the hepatic artery
bile ducts.
Fatty liver
Ingested alcohol is primarily
metabolized in the liver.
Acetaldehyde, formed when
alcohol is metabolized, damages
hepatocytes and impairs the
oxidation of fatty acids. As a
result, fat accumulates within
hepatocytes and liver lobules.
Other alcohol metabolism
by-products, including oxygen free
radicals, promote inflammation
Auto-
and may stimulate autoantibody antibodies
production.
Free
radicals
Focus on Cultural Diversity

FOCUS ON CULTURAL DIVERSITY
This feature provides essential guidelines
for culturally competent care. Biologic Variations among Cultures
As genetic science and our understanding of disease and pathol-
ogy have advanced, there is increasing recognition that differ-
ences between peoples of the world are more than skin deep.
Certain diseases and conditions are much more likely to develop
in some groups than in others; for example, sickle cell disease oc-
curs more frequently in people whose ancestors are from central
Africa, the Near East, the Mediterranean region, and parts of India;
Caucasian women of small stature and of Scandinavian heritage
have a higher risk of developing osteoporosis. Biologic variations
also may affect the way the body metabolizes drugs, leading to
an effect that is either less than or greater than anticipated. In
other cases, selected drugs may be found to be more effective for
people of one race than another.
PATHOPHYSIOLOGY LINKAGE
Acute Pain and Associated Manifestations

Manifestation Related Pathophysiology
PATHOPHYSIOLOGY LINKAGE
Localized, sharp, Nociceptors transmit pain stimulus along myelinated Aδ fibers to spinal cord, where it travels via the
Pathophysiology Linkage tables provide the
burning pain neospinothalamic tract to the thalamus. From the thalamus, the stimulus is distributed to the somatosensory pathophysiologic basis for major manifestations
cortex (perception and interpretation), the limbic system (emotional responses to pain), and brainstem
centers (autonomic nervous system responses). of the disorder to help the student develop a
deeper understanding of the disorder’s effects
Diffuse, dull, Transmission of nociceptive stimuli along unmyelinated C fibers to the spinal cord, and from there to the
aching pain thalamus via the paleospinothalamic tract. Stimuli are distributed from the thalamus to the somatosensory on the patient.
cortex, limbic system, and brainstem centers.
Increased heart rate, Activation of the sympathetic nervous system (SNS) with release of catecholamines, which stimulate
stroke volume, and blood receptors in the heart and blood vessels.
pressure; pupil dilation
Nausea, vomiting SNS activation causes decreased blood flow to the gut, with decreased gastric acid secretion and intestinal
motility; pain, anxiety cause stimulation of the vomiting center in the medulla.
Muscle tension Protective responses initiated by higher brain centers to reduce nociceptive stimuli.
Anxiety, fear Emotional responses to pain stimuli generated by limbic system.
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manifestations OF DISORDERS MANIFESTATIONS OF IMPENDING DEATH

Manifestation boxes summarize specific subjective
• Difficulty talking or swallowing
and objective manifestations of disorders. • Nausea, flatus, abdominal distention
• Urinary and/or bowel incontinence, constipation
• Decreased sensation, taste, and smell
• Weak, slow, and/or irregular pulse
• Decreasing blood pressure
• Decreased, irregular, or Cheyne-Stokes respirations
• Changes in level of consciousness
• Restlessness, agitation
• Coolness, mottling, and cyanosis of the extremities
Nursing Care of the Patient NURSING CARE OF THE PATIENT

Essential information needed for nursing care of various
Halo Fixation
disorders is described—detailed illustrations help students
understand the steps of the nursing process. • Maintain integrity of the halo external fixation device:
a. Inspect pins and traction bars for tightness; report loos-
ened pins to physician.
b. Tape the appropriate wrench to the head of the bed for
emergency intervention.
c. Never use the halo ring to lift or reposition the patient.
Loosening of the apparatus poses the risk of further dam-
age to the cord. It is the responsibility of the nurse to
maintain the integrity of the apparatus and the safety of
the patient.
• Assess muscle function and skin sensation every 1 hour in
the acute phase and every 4 hours thereafter:
a. Assess motor function on a scale of 0 to 5, with 0 being
no evidence of muscle contraction and 5 being normal
muscle strength with full range of motion (ROM).
b. Assess sensation by comparing touch and pain, moving
Medication Administration
from impaired to normal areas, and testing both the right
Drugs appropriate for the chapter disorders and left sides of the body.
are featured, as well as the related nursing Monitoring muscle function and skin sensation allows early
responsibilities and patient/family teaching. identification of potential neurologic deficits.
MEDICATION ADMINISTRATION
Increased Intracranial Pressure

OSMOTIC DIURETICS They cause a reduction in the rate of CSF production, thus reducing
mannitol (Osmitrol) the ICP.
urea Nursing Responsibilities
glucose • Monitor vital signs and electrolyte values closely.
• Assess fluid status throughout therapy.
Osmotic diuretics (hyperosmotic agents) draw fluid out of brain cells
• Monitor blood pressure and pulse before and during
by increasing the osmolality of the blood. The effects of these drugs
vary with the type of injury. Mannitol therapy is often initiated if the administration.
• Monitor renal laboratory studies closely.
patient’s ICP has exceeded 15 to 20 mmHg for at least 10 minutes.
• Use infusion pump to ensure accurate dosage.
Both IV bolus and continuous infusion techniques are used. Repeated
use of mannitol can lead to continual elevations in serum osmolal- INTRAVENOUS FLUIDS
ity, with attendant risk of seizures and a serious fluid and electrolyte Keeping the patient moderately dehydrated to maintain serum os-
imbalance. Urea is seldom administered IV because a severe local molality can be effective in reducing cerebral edema. When giving IV
reaction may result if leakage occurs at the injection site. Mannitol and fluids, closely monitor the osmolality of the solutions; if patients with
urea are used cautiously if renal disease is present. IICP are given hypo-osmolar solutions, increased cerebral edema
Nursing Responsibilities can occur. Preferred solutions include 0.45% to 0.9% sodium chlo-
• Monitor vital signs, urinary output, central venous pressure ride solutions.
(CVP), and pulmonary artery pressures (PAP) before and every Nursing Responsibilities
hour throughout administration. • Monitor fluid status closely.
• Assess for manifestations of dehydration. • Monitor neurologic status closely.
• Assess for muscle weakness, numbness, tingling, paresthesia, • Avoid administering solutions that become hypo-osmolar, such
confusion, and excessive thirst. as 5% dextrose in water.
• Assess for pulmonary edema while administering the
medication. OTHER PHARMACOLOGIC INTERVENTIONS FOR ICP
• Monitor neurologic status and intracranial pressure readings. • Antipyretics, such as acetaminophen, are used in conjunction
• Monitor renal function and serum electrolytes throughout with a hypothermia blanket to reduce hyperthermia, thereby
therapy. decreasing the high cerebral metabolism that contributes
• Do not administer the medication if crystals are present in to IICP.
solution. Administer with an inline filter. Observe infusion • Antiulcer drugs, such as histamine H antagonists (for example,
2
site frequently for infiltration. ranitidine [Zantac]) or sucralfate (Carafate), are used in patients
• Do not administer mannitol solution with blood. with ICP to decrease the development of stress ulcers.
• Antihypertensive agents, such as beta-adrenergic blocking
LOOP DIURETICS agents, may be used if the mean arterial pressure is high.
furosemide (Lasix) • Vasopressors may be used if the mean arterial pressure is low.
ethacrynic acid (Edecrin) • Anticonvulsants may be given to prevent or treat seizures.
Loop diuretics such as furosemide and ethacrynic acid inhibit so- Note: Because the patient with IICP often has an altered level of consciousness, patient
dium and chloride reabsorption at the ascending loop of Henle. and family teaching are not discussed in this box.
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Evidence for Nursing Care

Evidence for Nursing Care
Evidence for Nursing Care boxes provide
resources for additional review in applying The Patient with a Stroke
evidence to practice. Selected resources that nurses may find helpful when planning
evidence-based nursing care follow.
• Miller, E. L., Murray, L., Richards, L., Zorowitz, R. D., Bakas, T.,
Clark, P., & Billinger, S. A. (2010). Comprehensive overview
of nursing and interprofessional rehabilitation care of the
stroke patient: A scientific statement from the American Heart
Association. Stroke, 41(10), 2401–2448.
• Mink, J., & Miller, J. (2011). Stroke, part I: Opening the window
of opportunity for treating acute ischemic stroke. Nursing 2011,
41(1), 25–33.
• Mink, J., & Miller, J. (2011). Stroke, part 2: Respond aggressively
to hemorrhagic stroke. Nursing 2011, 41(3), 36–43.
PRACTICE ALERT! alerts

Alerts bring forward critical information for safe and effective
Warning Signs of a Flare nursing practice.
• Increased fatigue
• Pain, abdominal discomfort
• Rash
• Headache
• Fever
• Dizziness
SAFETY ALERT
Gastrointestinal bleeding is a risk for patients taking NSAIDs. Teach
patients to watch for bright red bleeding from the stomach (in vomitus)
or dark black bowel movements.
Moving Evidence into Action

These boxes focus on research into specific topics and how
the research relates to current nursing care. Critical-thinking
questions help students understand the material.
Moving Evidence into Action

Patients Undergoing an Awake Craniotomy
Brain mapping is a procedure conducted to identify the functional experience, updating the base for guidelines for preoperative, intra-
areas of the brain that control language and motor abilities. The pa- operative, and postoperative nursing interventions. Certainly, having
tient is awake during the surgery, and a handheld probe is used to surgery for a brain tumor, having a malignancy, and knowing one will
stimulate areas of the brain. The areas stimulated become temporarily be awake during the procedure are each traumatic, but when com-
inactivated (as evidenced by asking the patient to speak or move), so bined they can easily be overwhelming. Nursing care before the sur-
that the surgeon knows which areas to avoid when removing a brain gery must focus on meeting the emotional needs of the patient as
tumor. This study (Manchella et al., 2011) examined the experiences well as providing interventions (such as active listening and focused
of patients in term of their feelings, what they think about, and how discussions) to relieve anxiety and fear. Because hearing the surgeon
they approach this type of surgery without an anesthetic. explain what was being done was very important to the patients, it is
Findings from the study illustrated the complexity of the experience important that the nurse discuss this aspect with the physician.
and the effect on the patient. Preoperatively, the patients felt a part of Moving Knowledge into Action
the decision making about being awake during the surgery, needed 1. Provide examples of leading statements you might use to dis-
strong emotional support, kept busy to remain distracted, and avoided cuss awake surgery with a patient.
thinking about how they would handle the surgery itself. During the 2. In this study, patients wanted to see their family members imme-
surgery, patients concentrated on doing what they were asked to do diately after surgery to reassure themselves that they were back
and having their senses (especially hearing) play the strongest role. to normal. Very few hospitals allow visitors in the recovery area.
After the surgery, the patients tested their ability to speak and move to What process would you use to change this general rule? How
ensure they had returned to normal, felt tired, and were surprised that would you handle the same request from other patients if the
no typical postoperative complications (e.g., nausea, pain) occurred. rule were changed for this population?
Implications for Nursing 3. Considering the surgery, describe the immediate postoperative
There is very little in the literature about nursing care of patients who care necessary. What would be the priority assessments?
are awake during surgery. This study identified information about the
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Case Study & Nursing Care Plan

The two-column Case Study & Nursing Care Plan includes Assessment,
Diagnoses, Expected Outcomes, Planning and Implementation,
Evaluation, and Clinical Reasoning in Patient Care.
CASE STUDY & NURSING CARE PLAN A Patient with Gonorrhea

Janet Cirit, a 33-year-old legal secretary, lives in a suburban Mid- • Sexual Dysfunction related to the impaired relationship and fear
western community. She is unmarried but dating a man named Jim of reinfection
Adkins, who lives in an adjacent suburb. Ms. Cirit visits her gynecolo- expecteD outcomes
gist because her periods have become irregular and she is experi- • Patient will experience relief of pain, indicating that the infection
encing pelvic pain and an abnormal amount of vaginal discharge. has been eradicated.
Recently she has developed a sore throat. The pelvic pain has begun • Patient will verbalize that she has nothing to be ashamed of
to disrupt her sleeping pattern, and she is concerned that she might and that she has been wise to seek treatment as soon as
have cancer because her mother recently died of ovarian cancer. symptoms occurred.
Assessment • Patient will verbalize that she will insist her partner use
When Ms. Cirit arrives for her appointment at the gynecologist’s condoms during future sexual activity.
office, Marsha Davidson, the nurse practitioner, interviews her. plAnning AnD implementAtion
Ms. Davidson completes a thorough medical and sexual history, • Administer ceftriaxone IM and azithromycin PO as ordered.
including questions about her menstrual periods, pain associated • Emphasize the need for regular Pap smears and pelvic exami-
with urination or sexual intercourse, urinary frequency, most recent nations because of the family history of ovarian cancer.
Pap smear, birth control method, history of STI and drug use, and • Discuss feelings and concerns about the diagnosis of gonor-
types of sexual activity. Ms. Cirit reports her symptoms and her con- rhea. Stress that such a diagnosis does not reflect on one’s
cern about ovarian cancer. She also indicates that she is taking oral self-worth as a person.
contraceptives and therefore sees no need for her boyfriend to use • Teach how to talk with a future sexual partner about
a condom because she believes their relationship is monogamous. condom use.
Physical examination reveals both pharyngeal and cervical in-
flammation, and lower abdominal tenderness. Her temperature is evAluAtion
37.0°C (98.5°F). There are no signs or symptoms of pregnancy. A week later during her follow-up visit, Ms. Cirit states that she is
The gynecologist orders a Pap smear and cultures of the cer- feeling much better and sleeping well at night since the pain has
vix, urethra, and pharynx to evaluate for gonorrhea and chlamydial ended. She has terminated her relationship with Mr. Adkins and is
infection. Blood is drawn for WBC. Test results are positive for gon- considering joining a health club in the hope of increasing her level
orrhea and negative for chlamydia. The WBC is slightly elevated, of fitness and perhaps meeting someone new.
indicating possible salpingitis. Because Mr. Adkins has been clinical Reasoning in patient care
Ms. Cirit’s only sexual partner, it is clear that he is the source of 1. How are Ms. Cirit’s manifestations related to the infectious
infection and needs to be treated as well. process of gonorrhea?
DiAgnoses 2. Should the nurse have suggested that Ms. Cirit also be tested
• Acute Pain related to the infectious process for HIV? Why or why not?
• Anxiety related to fear about possible cancer 3. Develop a care plan for Ms. Cirit for the nursing diagnosis
• Situational Low Self-Esteem related to shame and guilt Impaired Social Interaction.
because of having an STI See Evaluating Your Response in Appendix B.
End of Unit clinical scenario

This activity presents the student an opportunity to focus on setting
priorities while managing a group of patients. Included are NCLEX®
questions that evaluate prioritization, delegation and safe nursing care.
CLINICAL SCENARIO
Directions: Read the following clinical scenarios and answer the temperature 36.4°C (97.6°F) with clammy skin, pulse 100 bpm,
questions that follow. To complete this exercise successfully, you respirations 24/min, and blood pressure of 168/94 mmHg. She
will utilize not only knowledge of the content in this unit, but also is requesting pain medication for the back pain.
principles related to priority setting and maintaining patient safety. ● Mrs. Fox is an 86-year-old who was transferred from the medi-
You have been assigned to work with the following four pa- cal ICU yesterday. She was admitted after being found in a
tients for the 0700 shift on a medical-surgical unit. Significant data comatose state by her daughter. On admission her blood sugar
obtained during report is as follows: was 45 mg/dL, serum sodium was 128 mEq/L, temperature
● Mr. Blew is a 54-year-old who is admitted with complaints was 35.9°C (96.6°F), and she had a heart rate of 50 bpm. Vital
of polydipsia, polyuria, and polyphagia. There is a fruity odor signs this a.m. are temperature 36.9°C (98.4°F), pulse 78 bpm,
to his breath and he seems confused at times. Vital signs on respirations 18/min, and blood pressure 140/86 mmHg. She is
admission are temperature 37.2°C (99°F), pulse 90 bpm, res- due for electrolytes to be drawn at 0730.
pirations 30/min and deep, and blood pressure 110/68 mmHg. ● Mr. Rite is a 56-year-old who was admitted 4 days ago after
His blood glucose is 650 mg/dL on admission at 0630. falling from a ladder and hitting his head. He is complaining
● Mrs. Rant is a 65-year-old who is admitted with severe back of a headache and thirst even after drinking 2000 mL of fluids
pain in the flank area on the right side, nausea, and vomit- during the night. Vital signs are temperature 37.8°C (100°F),
ing. She is being evaluated for treatment due to renal calculi. pulse 98 bmp, respirations 14/min, and blood pressure
She has a history of hyperparathyroidism. Vital signs are 114/84 mmHg.
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About the Authors iii Extended Care 39, Rehabilitation 40, Home
Thank You v Healthcare 40, Hospice and Respite Care 41,
Home Health Nursing Care 42
Preface vii
UNIT 2 Alterations in Patterns of Health 48
UNIT 1 Dimensions of Medical-Surgical
Nursing 1 Chapter 4 Nursing Care of Patients Having
Surgery 49
Chapter 1 Medical-Surgical Nursing in the
21st Century 2 Surgery 50
Classification of Surgical Procedures 50, Settings
Core Competencies for Safe and Effective for Surgery 50, Informed Consent 51, Surgical
Healthcare 3 Risk and Safety 51
Clinical Reasoning/Judgment in the Interprofessional Care 56

Nursing Process 3 Nursing Care 66
Clinical Reasoning/Judgment 3, The Nursing
Chapter 5 Nursing Care of Patients Experiencing
Process 5
Loss, Grief, and Death 79
Guidelines for Nursing Practice 9
Codes for Nurses 9, Standards of Nursing Practice 10 Theories of Loss, Grief, and Dying 80
Freud: Psychoanalytic Theory 80, Bowlby: Attachment
Legal and Ethical Dilemmas in Nursing 11 Theory 80, Engel: Acute Grief, Restitution, and
Roles of the Nurse in Medical-Surgical Long-Term Grief 80, Lindemann: Categories of
Nursing Practice 11 Symptoms 81, Caplan: Stress and Loss 81,
Kübler-Ross: Stages of Coping with Loss 81
The Nurse as Caregiver 11,The Nurse as
Educator 12, The Nurse as Advocate 13, Factors Affecting Responses to Loss 81
The Nurse as Leader and Manager 13, The Nurse Age 81, Social Support 81, Families 82, Culture
as Researcher 14 and Spiritual Practices 82, Spiritual Beliefs 82,
Rituals of Mourning 83, Nurses’ Response to
Chapter 2 Informatics and Evidence-Based Patients’ Loss 84
Practice in Medical-Surgical
End-of-Life Care 84
Nursing 17
Legal and Ethical Issues 85, Settings and Services
Nursing Informatics 17 for End-of-Life Care 86, Physiologic Changes
Nursing Informatics Competencies 18 in the Dying Patient 86, Support for the Patient
and Family 88, Death 88
Information Technology in Healthcare 18
Interprofessional Care 89
Information Technology in Nursing Practice 18
Nursing Care 89
Evidence-Based Practice 19
History and Factors That Promote EBP in Nursing 19, Chapter 6 Nursing Care of Patients with Problems
EBP Overview 20, Starting with the Clinical Question 20, of Substance Abuse 96
Nursing Research as External Evidence 20, Relationship
between Research Process and Nursing Process 21, The Patient with Substance Abuse
Use of Technology in EBP: Locating the Evidence 21, Problems 97
Research Approaches, Designs, and Methods 22, Pathophysiology, Manifestations, and
Implementing EBP in Medical-Surgical Nursing 24, Complications 97, Risk Factors 97, Characteristics
Ethical Considerations of EBP 25 of People Who Abuse Substances 99
Chapter 3 Health and Illness Care of Adults 27 Addictive Substances and their Effects 100
Caffeine 100, Nicotine 100, Cannabis 101,
Health and Wellness 28
Alcohol 101, CNS Depressants 102,
Factors Affecting Health 28 Psychostimulants 102, Opiates 103,
Health Promotion and Maintenance 33 Hallucinogens 103, Inhalants 104
Disease and Illness 35 Interprofessional Care 105

Disease 35, Illness 35 Diagnostic Tests 105, High-Acuity
Care 105, Rehabilitation 107
Health and Illness Care 38
Nursing Care 108
Primary Care 39, Care and Disease Management 39,
Transitional Care 39, Community-Based Care 39, Impaired Nurses 114
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Chapter 7 Nursing Care of Patients Experiencing Chapter 10 Nursing Care of Patients with Altered
Disasters 117 Fluid, Electrolyte, and Acid–Base
Disasters and Emergencies 118 Balance 177
The Disaster Continuum 119 Overview of Fluid and Electrolyte
Balance 178
Terrorism 120
Body Fluid Composition 178, Body Fluid
Types of Disasters with Common Distribution 178, Body Fluid Movement 181,
Injuries 121 Body Fluid Regulation 182, The Patient with
Hurricanes and Tornadoes 121, a Fluid Volume Deficit 183
Thunderstorms 123, Earthquakes and Fluid and Electrolyte Imbalances 183
Tsunamis 124, Snowstorms 124,
Hazardous Materials 124, Explosives 124 Fluid Imbalance 183
Casualty Management 125
Isolation and Personal Protective Equipment 126, Nursing Care 187
Recording Victim Data 126, Crowd Control 126, The Patient with a Fluid Volume Excess 189
Psychosocial Needs 126 Interprofessional Care 189
Nursing Care 126 Nursing Care 191
Sodium Imbalance 193
UNIT 3 Pathophysiology and Patterns The Patient with Hyponatremia 193
of Health 135 Interprofessional Care 194

Nursing Care 194
Chapter 8 Genetic Implications of Adult The Patient with Hypernatremia 195
Health Nursing 136 Interprofessional Care 195
Integrating Genetics into Nursing Nursing Care 195
Practice 136 Potassium Imbalance 196
Genetic Basics 137 The Patient with Hypokalemia 196
Cell Division 138, Chromosomal Interprofessional Care 197
Alterations 138, Genes 139
Nursing Care 198
Principles of Inheritance 140 The Patient with Hyperkalemia 200
Mendelian Pattern of Inheritance 140, Variability
in Classic Mendelian Patterns of Inheritance 141, Interprofessional Care 201
Multifactorial (Polygenic or Complex) Nursing Care 201
Disorders 143
Calcium Imbalance 203
Interprofessional Care 143 The Patient with Hypocalcemia 204
Genetic Testing 143
Nursing Care 144
Nursing Care 206
Visions for the Future 148 The Patient with Hypercalcemia 207
Chapter 9 Nursing Care of Patients in Pain 151
Nursing Care 208
Myths and Misconceptions Magnesium Imbalance 209
About Pain 152 The Patient with Hypomagnesemia 209
Neurophysiology of Pain 152 Interprofessional Care 210
Pain Theories 152, Physiology 153, Pain
Pathways 154, Pain Modulation 154 Nursing Care 210
The Patient with Hypermagnesemia 210
Types and Characteristics
of Pain 154
Acute Pain 155, Chronic Pain 156, Nociceptive Nursing Care 211
Pain 157, Neuropathic Pain 157 Phosphate Imbalance 211
Adverse Effects of Pain 158 Overview of Normal Phosphate Balance 211,
The Patient with Hypophosphatemia 211
Factors Affecting Responses
to Pain 158 Interprofessional Care 212
Age 158, Gender 158, Sociocultural Nursing Care 212
Influences 158, Psychologic Influences 159 The Patient with Hyperphosphatemia 212
Interprofessional Care 159 Interprofessional Care 212
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Acid–Base Disorders 213 Chapter 13 Nursing Care of Patients

Regulation of Acid–Base Balance 213 with Altered Immunity 297
Buffer Systems 213, Respiratory System 213, Overview of the Immune System 298
Renal System 214, Assessing Acid–Base
Balance 214 Assessing Altered Immune
Acid–Base Imbalance 214 System Function 298
Health History 298, Physical Assessment 299
Compensation 215, The Patient with Metabolic
Acidosis 215 The Patient with a Hypersensitivity
Interprofessional Care 219 Reaction 299
Nursing Care 220 Pathophysiology 299
The Patient with Metabolic Alkalosis 221 Interprofessional Care 303
Interprofessional Care 221 Nursing Care 305
Nursing Care 222 The Patient with an Autoimmune
The Patient with Respiratory Acidosis 223 Disorder 306
Interprofessional Care 223 Pathophysiology 306
Nursing Care 224 Interprofessional Care 307

The Patient with Respiratory Alkalosis 225 Nursing Care 307
Interprofessional Care 226 The Patient with a Tissue Transplant 308
Chapter 11 Nursing Care of Patients Experiencing Nursing Care 311
Trauma and Shock 229 Impaired Immune Responses 315
The Patient Experiencing Trauma 230 The Patient with HIV Infection 315
Components of Trauma 230, Types of Trauma 230, Incidence and Prevalence 315, Pathophysiology
Effects of Traumatic Injury 231 and Manifestations 316

The Patient Experiencing Shock 244 Chapter 14 Nursing Care of Patients
Overview of Cellular Homeostasis and
Hemodynamics 244, Pathophysiology 244,
with Cancer 333
Types of Shock 248 Incidence and Mortality 334
Interprofessional Care 251 Risk Factors 334
Normal Cell Growth 338, The Cell Cycle 338,
Differentiation 338, Theories of Carcinogenesis 339,
Chapter 12 Nursing Care of Patients Known Carcinogens 339, Types of Neoplasms 340,
with Infections 260 Characteristics of Malignant Cells 341, Tumor
Invasion and Metastasis 342
Overview of the Immune System 261
Immune System Components 261, Innate Physiologic and Psychologic Effects
Immune Response 265, Adaptive Immune of Cancer 343
Response 268, The Patient with Natural Disruption of Function 344, Hematologic
or Acquired Immunity 272 Alterations 344, Infection 344, Hemorrhage 344,
Interprofessional Care 274 Anorexia-Cachexia Syndrome 344, Paraneoplastic
Syndromes 345, Pain 345, Physical Stress 345,
Nursing Care 275 Psychologic Stress 346
Normal Immune Responses 277 Interprofessional Care 346
The Patient with Tissue Inflammation 277 Nursing Care 361
Pathophysiology and Manifestations 277,
Complications 278
UNIT 4 Responses to Altered Integumentary
Structure and Function 376
Nursing Care 280
Chapter 15 Assessing the Integumentary
The Patient with an Infection 282
Pathophysiology 282, Stages of the Infectious
System 377
Process 284, Complications 284 Anatomy, Physiology, and Functions of the
Interprofessional Care 285 Integumentary System 377
The Skin 377, The Hair 379, The Nails 379
Nursing Care 292
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Assessing the Integumentary The Patient with Actinic Keratosis 409

System 380 The Patient with Nonmelanoma
Diagnosis 380, Genetic Considerations 381, Skin Cancer 409
Health Assessment Interview 381,
Incidence 409, Risk Factors 410,
Physical Assessment 382
Pathophysiology 410
Chapter 16 Nursing Care of Patients with Interprofessional Care 411
Integumentary Disorders 390 Nursing Care 412
Common Skin Problems and Lesions 391 The Patient with Melanoma 414
The Patient with Pruritus 391 Incidence 414, Risk Factors 414,
Pathophysiology 414
The Patient with Dry Skin (Xerosis) 391
The Patient with Benign Skin
Nursing Care 416
Lesions 392
Cysts 392, Keloids 392, Nevi 393, Skin Trauma 419
Angiomas 393, Skin Tags 393, Keratoses 393 The Patient with a Pressure Ulcer 419
The Patient with Psoriasis 393 Incidence 419, Pathophysiology 420,
Risk Factors 420
Pathophysiology 394, Manifestations 394
Infections and Infestations of the Skin 396 The Patient with Frostbite 424
The Patient with a Bacterial Infection The Patient Undergoing Cutaneous
of the Skin 396 and Plastic Surgery 424
Pathophysiology 396 Cutaneous Surgery and Procedures 424,
Plastic Surgery 425
Nursing Care 426
Nursing Care 398
Hair and Nail Disorders 428
The Patient with a Fungal Infection 399
The Patient with a Disorder
Pathophysiology 399
of the Hair 428
The Patient with a Parasitic Infestation 401 Nursing Care 429
Pathophysiology 401
The Patient with a Disorder of the Nails 429
The Patient with a Viral Infection 401 Nursing Care 429
Pathophysiology 401
Interprofessional Care 403 Chapter 17 Nursing Care of Patients
with Burns 432
Nursing Care 403
Inflammatory Disorders of the Skin 405 Types of Burn Injury 433
Thermal Burns 433, Chemical Burns 433, Electrical
The Patient with Dermatitis 405 Burns 433, Radiation Burns 434
Pathophysiology 405
Factors Affecting Burn Classification 434
Interprofessional Care 406 Depth of the Burn 434, Extent of the Burn 436
Nursing Care 406
Burn Wound Healing 438
The Patient with Acne 407
The Patient with a Minor Burn 438
Pathophysiology 407
Pathophysiology 438
Nursing Care 408
Nursing Care 439
The Patient with Pemphigus Vulgaris 408
The Patient with a Major Burn 439
The Patient with Lichen Planus 409 Nursing Care 450
Malignant Skin Disorders 409
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UNIT 5 Responses to Altered Endocrine The Patient with Disorders of the Posterior
Function 460 Pituitary Gland 497
Pathophysiology and Manifestations 498
Chapter 18 Assessing the Endocrine System 461 Interprofessional Care 498
Anatomy, Physiology, and Functions Nursing Care 499
of the Endocrine System 462
Pituitary Gland 462, Thyroid
Chapter 20 Nursing Care of Patients
Gland 463, Parathyroid Glands 463, Adrenal with Diabetes Mellitus 501
Glands 464, Pancreas 464, Gonads 464
Diabetes Mellitus 502
An Overview of Hormones 465 Incidence and Prevalence 502, Overview of Endocrine
Assessing Endocrine Function 466 Pancreatic Hormones and Glucose Homeostasis 502,
Pathophysiology of DM 504, DM in the Older
Diagnostic Tests 466, Genetic Influences 466,
Adult 506
Health Assessment Interview 470, Physical
Assessment 471 Interprofessional Care 506
Complications of Diabetes Mellitus 520
Chapter 19 Nursing Care of Patients Chronic Complications 523
with Endocrine Disorders 475 Nursing Care 527
Disorders of the Thyroid Gland 476
The Patient with Hyperthyroidism 476 UNIT 6 Responses to Altered
Pathophysiology and Manifestations 476 Gastrointestinal Function 537
Nursing Care 480 Chapter 21 Assessing the Gastrointestinal
System 538
The Patient with Hypothyroidism 482
Pathophysiology and Manifestations 483 Nutrients 538
Interprofessional Care 483 Carbohydrates 539, Proteins 539, Fats (Lipids) 540
Nursing Care 483 Vitamins 540

Minerals 540
The Patient with Cancer of the Thyroid 487
Anatomy, Physiology, and Functions
Disorders of the Parathyroid Glands 487
of the GI System 542
The Patient with Hyperparathyroidism 488 The Mouth 542, The Pharynx 543,
Pathophysiology and Manifestations 488 The Esophagus 543, The Stomach 543, The Small
Interprofessional Care 488 Intestine 543, The Large Intestine 544, The Accessory
Digestive Organs 544
Nursing Care 488
Metabolism 545
The Patient with Hypoparathyroidism 488
Pathophysiology and Manifestations 488 Assessing Gastrointestinal Function 545
Diagnostic Tests 545, Genetic Considerations 545,
Interprofessional Care 489 Nutrition Screening and Assessment 545
Nursing Care 489
Disorders of the Adrenal Glands 489
Chapter 22 Nursing Care of Patients
with Nutritional Disorders 563
The Patient with Cushing’s Syndrome 489
Pathophysiology 489, Manifestations 489 The Patient with Obesity 564
Incidence and Prevalence 564, Risk Factors 564,
Overview of Normal Physiology 565,
Nursing Care 491 Pathophysiology 565, Complications of Obesity 565
The Patient with Chronic Adrenal Interprofessional Care 566
Insufficiency 493 Nursing Care 570
The Patient with Malnutrition 575
Interprofessional Care 494 Incidence and Prevalence 575, Risk Factors 575,
Nursing Care 494 Pathophysiology 575, Manifestations 576
The Patient with Pheochromocytoma 496 Interprofessional Care 576
Disorders of the Pituitary Gland 497 Nursing Care 580
The Patient with Disorders of the Anterior The Patient with an Eating Disorder 582
Pituitary Gland 497 Anorexia Nervosa 582, Bulimia Nervosa 582,
Binge-Eating Disorder 583
Pathophysiology and Manifestations 497
DESIGN SERVICES OF
# 151615 Cust: Pearson Au: LeMone Pg. No. xviii C/M/Y/K
S4carlisle
Contents xix
Chapter 23 Nursing Care of Patients with Upper Chapter 24 Nursing Care of Patients
Gastrointestinal Disorders 588 with Bowel Disorders 625
The Patient with Nausea Disorders of Intestinal Motility 625
and Vomiting 589 The Patient with Diarrhea 626
Pathophysiology 589 Pathophysiology 626, Manifestations 626,
Interprofessional Care 589 Complications 626
Disorders of the Mouth 591 Nursing Care 628
The Patient with Stomatitis 591 The Patient with Constipation 629
Pathophysiology and Manifestations 593 Pathophysiology 629,
Manifestations and Complications 630
Nursing Care 594
Nursing Care 632
The Patient with Oral Cancer 596
Pathophysiology and Manifestations 596 The Patient with Irritable Bowel
Syndrome 633
Nursing Care 597
Disorders of the Esophagus 599
Nursing Care 634
The Patient with Gastroesophageal
The Patient with Fecal Incontinence 635
Reflux Disease 599
Pathophysiology 635
Nursing Care 636
Nursing Care 601
Acute Inflammatory and Infectious
The Patient with Hiatal Hernia 603 Bowel Disorders 637
The Patient with Impaired The Patient with Appendicitis 637
Esophageal Motility 604 Pathophysiology 637, Manifestations 637,
The Patient with Esophageal Cancer 604 Complications 638
Pathophysiology 604, Manifestations 605 Interprofessional Care 638
Interprofessional Care 605 Nursing Care 639
Nursing Care 605 The Patient with Peritonitis 640
Disorders of the Stomach Pathophysiology 640, Manifestations 640,
and Duodenum 606 Complications 641
Overview of Normal Physiology 606 Interprofessional Care 641
The Patient with Gastrointestinal Nursing Care 642
Bleeding 607 The Patient with Gastroenteritis 643
Pathophysiology 607 Pathophysiology 643, Manifestations 644,
Interprofessional Care 607 Complications 644

The Patient with Peptic Ulcer Disease 609 Nursing Care 648
Risk Factors 609, Pathophysiology 609, The Patient with a Protozoal Bowel
Manifestations 612, Complications 612, Infection 648
Zollinger-Ellison Syndrome 612 Pathophysiology and Manifestations 649
The Patient with Gastritis 616 The Patient with a Helminthic Disorder 651
Pathophysiology 617 Pathophysiology 651
The Patient with Cancer of the Stomach 619 Chronic Inflammatory Bowel Disorders 652
Risk Factors 619, Pathophysiology 619,
The Patient with Inflammatory Bowel
Manifestations 619
Disease 652
Interprofessional Care 620 Ulcerative Colitis 653, Crohn’s Disease 654
DESIGN SERVICES OF
# 151615 Cust: Pearson Au: LeMone Pg. No. xix C/M/Y/K
S4carlisle
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and observed, he had staid too long, and that she needed rest. Rest,
repeated she, detaining him, oh, be not so deceived; I need no rest, I
can find none that cheers me like seeing you. He again took his seat,
and with composure observed, that she had promised him coffee:
and that he would remain, on condition she would try to be quiet and
listen to our chat. She smiled, and I took my post.
Again he offered to leave her, when, with composure, she said, my
dear Percival you must indulge me; this is the last time I will
mention business which may distress you; but I shall not be easy
until I have finally settled my concerns with this world. Whatever
you find done in this way, when I am dead, remember what I have
already said, I have done all in love, and have been as just as I could
be to you. You will find my will in that cabinet, continued she,
directing his attention to it. Lady Maclairn has my instructions in
respect to all that it contains except the will; she will inspect it in
your presence.
Here is a present for my niece. May it prove to her, what of late it
has been to me, a blessing! The captain paced the room in silence.
This picture, my dear and invaluable friend, continued she,
addressing me, you will see buried with me. She gazed intently on the
miniature of Mr. Philip Flint, which she wears in her bosom. Poor
fellow! added she mournfully, he will not soon forget Lucretia! He
will regret that he was not with me.—I cannot stand this! said the
agitated captain, and were I not convinced, Lucretia, that even in this
depression of your mind, there is a healing power more potent than
all human aids, you would break my heart.—I will spare your
feelings, answered she, only let me say a few words more: I wish to
have your concurrence. I have nominated Mr. Greenwood to succeed
Snughead in the Farefield living; but if you think he would like the
presentation better from you, speak, and it shall be so managed. “I
do not believe,” added Mrs. Allen, “that the captain could have
uttered a word, had his friend’s being made an archbishop depended
on it; he was quite overcome by his feelings.”
“At length he ventured to say, should you like to see Mr.
Greenwood? He would be sorry to see me, replied she; he is a good
man, and will pity me; but I wish not to see him. I have no want of
his assistance;” she raised her eyes to Heaven, and paused. “You may
imagine,” continued Mrs. Allen, “that her exertions had subdued her.
The captain no sooner left her, than she went to her bed; and I have
the comfort of quitting her in a peaceful sleep.”
This recital, my Lucy, will affect poor Mary; but it will do her no
harm hereafter. Her mind wants firmness for the trials of life; and
she must acquire strength by the usual means. I have occasion for
more patience and fortitude than I possess. I tremble for the
consequences which will result to Mrs. Allen, should Miss Flint
continue long in her present condition. What will you say to the cares
and attention that devote my dear friend to her room the whole day?
What will you say to her swelled legs, got by watching her through
half the night? Will it be any comfort to you, when she is on a sick
bed, to be told that her piety and prayers are the cordials that quiet
the perturbed spirit of the miserable invalid? I have yet much to do
with my rebellious one; and I honestly confess, that, sincerely as I
rejoice at Miss Flint’s present temper of mind, I should murmur to
give a saint to her funeral obsequies. My serious remonstrances have
answered; Mrs. Allen is gone to bed, and I will take care she shall not
quit it to-night, to traverse half clothed, the passages to that of
another.
What with fogs within, and fogs without, it has been necessary for
me to make a sun of my own. Sir Murdoch has undertaken to teach
me to paint in oil colours; and I have begun to copy a landscape “très
riant,” for I cannot help laughing at my imitation of a good copy.
In continuation.
I was summoned below stairs. The enclosed will explain the cause.
Sir Murdoch and his son set out for Putney to-morrow morning; and
we are in a bustle; and somewhat anxious about the roads and cold
weather. I must help Lady Maclairn in this alarm.
Adieu, your’s,
R. Cowley.
LETTER LXII.
From Mr. Serge to Sir Murdoch Maclairn.
Putney, Dec. 3.
My dear and honoured friend! It is all over with Jeremiah Serge!

The public papers will tell you that he is desolate. To-morrow I shall
lose sight of her precious remains! But what of that! Do I not see her
always before me? Do I not hear her voice, and the blessed
consolations she gave me. My name was in the last sigh that
conveyed her to her God! Oh! she was a child, Sir Murdoch, worthy
of a heavenly Father! She was too good to be lent me long! and yet I
never forgot to be grateful for the loan: my daily prayers were thanks
to God, for the blessings she imparted! so affectionate, so gentle, so
wise, and yet so young! What a bulwark of defence has my age and
weakness lost! I do not know why I write to you; but I am so
oppressed by my thoughts, and my kind friends here fatigue me.
They cannot help it. They do for the best; but what can be done for
me! Is it not hard to see the sapless trunk left to the wintry blasts;
and the blossoms of the spring cut off? If my child had been spared
only a little while, she might have closed my eyes, and I had been at
rest. But I must not murmur against God! My Caroline warned me
not to grieve as “one without hope.” And I will hope, Sir Murdoch,
that my present feelings will soon effect my deliverance. I shall soon
be re-united to my child. I am very ill, and I think it is better to tell
you what also disturbs me in this hour of tribulation before I send
away this letter. I have not been negligent in regard to my worldly
concerns, as these relate to the security of my wife and children; for I
lost no time, in executing that duty, after you had so graciously
consented to be my children’s friend. But my heart is now set upon
seeing you and Malcolm once more before I die. You are a good man,
Sir Murdoch, and, in the sight of God, that is the only title that will
survive you. I think you will not refuse to come to me: no comfort on
earth would be so welcome; but do not delay your journey, if you
mean to see me; for indeed I am sinking fast. My poor wife is on a
sick bed; she might have foreseen the blow more than she did, but we
have all our faults! Poor soul! She finds at this hour that life needs
more than a doublet of silk, to guard the pilgrim in his rough
journey! I am sure Malcolm will second me in my request. Tell him,
that poor Caroline spoke of him not an hour before she died, and
called him her good brother Malcolm.
God preserve you, Sir Murdoch, from knowing the sorrow which
fills the heart of
Jeremiah Serge.
LETTER LXIII.
From Miss Cowley to Miss Hardcastle.
Friday morning.
My letter[1] of Monday last contained the intelligence of the good

baronet’s safety, and the comfortable hopes that are entertained at
Putney, that Mr. Serge will not need executors to his will, for some
time at least; for the sight of the travellers has been a cordial to him.
This morning we had another letter; it was from Malcolm; all the
business which occasioned the journey had been finished to poor Mr.
Serge’s contentment; but he had exerted himself too much; and the
gout had overtaken him. Malcolm adds, that the doctor regards this
indisposition as favourable to his friend’s general health, and that he
is chief nurse; Mrs. Fairly attends her mother with assiduity, though
unwell herself; she is, he says, the shadow of the Leonora we know,
and he thinks her in a consumption. Her husband, from time to time,
attends her; but his reception is cold and ceremonious in Mr. Serge’s
room, and he is not less restrained on his part with the guests. Sir
Murdoch is in perfect health, and the counsellor shares, in his leisure
hours, and contributes to his amusement.
1. This letter does not appear.
Lady Maclairn summons me to perform my part of the task we
have before us; she has finished her part of it, and I have to fill the
second sheet of paper to Putney. You will soon find me with you
again; but my good father must have this hour, and the satisfaction
of knowing that his wife is easy and reasonable, as is your
Rachel Cowley.
CHAP. X.
LETTER LXIV.
Sunday morning.
Will my Lucy need from me the obvious reflexions, which will result
from the perusal of this letter? “No:” nor have I time to make them,
though the impressions on my mind are such as will indelibly
remain, as admonitions to warn me against too much security in this
world’s air bubbles!
I had so well sustained my part with my pen, in writing to Sir
Murdoch, that I had produced a cheerfulness on the pensive brow of
his wife; and she detained me with her, until it was too late to finish
my letter to you. I therefore continued to read and chat with my
friend till near the dining hour. The appearance of Doctor Douglass
was nothing new; but we were equally struck with his manner and
countenance; and her ladyship, with alarm, asked him, whether
Lucretia was worse. “No,” replied he, with visible distress, “there is
no material change; but she has asked for you.” Lady Maclairn
immediately quitted us to go to her sister’s room. “She is dying,”
observed I, “you think so, I am certain; why do you flatter Lady
Maclairn with hopes?” “Poor creature!” answered he, “I wish she had
only this shock to support, there would then be little to justify my
fears for her; but I am a coward, Miss Cowley, and you must assist
me, and yet I tremble even in soliciting your aid; for these exertions
can do you no good.” “Never think of me,” said I eagerly. “What are
the dreadful tidings you bring?” “That a sinner is departed,”
answered he with solemnity; “that Lady Maclairn has no longer a
brother. Let me conduct you to your apartment,” continued he,
seeing me pale and trembling, “I must consult you; and we shall be
interrupted here.” I made no reply; but yielded to his assistance.
A burst of tears relieved me. “Wherefore is it,” observed poor
Douglass, with compassion, “that you seem destined, by Providence,
to be the support of this unfortunate family; and, by the continual
exertions of your fortitude and humanity, thus to diminish your own
comforts and weaken your health?” I admire you, and I reverence
your Mrs. Hardcastle; but your strength of mind is uncommon! “Try
it,” replied I, “let me hear the whole of this dreadful affair; it cannot
be worse than I apprehend.” “Nor is it better,” answered he; “and we
have to guard against surprises. It must be discovered. The public
papers will have the intelligence, and Lady Maclairn must be
prepared; are you equal to the task?” “I trust I am,” answered I,
“otherwise my strength of mind is no virtue.” He grasped my hand,
and said some words, expressive of his approbation, then proceeded
to inform me, that Captain Flint had found on his table the preceding
evening, on returning from his sister’s, the packet which he now
produced. “I was sent for,” added the doctor, “and we passed nearly
the whole night in reading the contents, and consulting the best
means of communicating them to Lady Maclairn. The captain
declared he was unable to do it; and thought himself peculiarly
disqualified for the office, it being no secret, that he despised the
man, and was not surprised at his end.” “I have no heart on such
occasions,” continued Douglass, rising and pacing the room. “I have
a trick of looking beyond “this diurnal sphere,” and I hate to
announce the death of the wicked. There are the letters; I will leave
you for an hour and then return; you may want me as a physician.”
To the hasty perusal of them, followed my thanks to Providence for
the absence of Sir Murdoch; and without suffering the energy of my
mind to relax, I sent for Lady Maclairn to my room. She instantly
perceived my emotion, and I at once acknowledged that I had bad
news to communicate from Jamaica; and which Captain Flint was
unequal to the task of doing. She gasped for breath. “Nothing can
equal,” continued I, “Mr. Philip Flint’s solicitude for you, thank God!
he has stood the shock: his friends are without alarm for him. Mr.
Flamall’s death must be supported, my dear Lady Maclairn; let me
see you composed.” “It was sudden?” said she, fixing her eyes on my
face, “It was——I made no other answer, than falling on her shoulder
and weeping.” “It is enough,” said she, trembling and sinking from
my embrace. I was terrified, for she did not faint as I expected, but
with her eyes fixed, and with a deadly groan she articulated the name
of Duncan. I immediately perceived the dreadful idea, which had
taken possession of her mind. “He is at rest, my dear friend,” said I,
“and now blessed for his faithfulness to you.” I was proceeding, but
she heard me not. Horror had transfixed her to her seat. She was as
cold as marble, and not a tear fell. I rang the bell with violence. The
doctor entered at the same moment; he instantly bled her, and she
was put into my bed. Douglass watched her, under great uneasiness,
until she appeared to me to be dead. I really thought she was, when
her eyes closed and her stiffened limbs relaxed. “Take courage,” said
he, “the worst is passed; she will recover.” The event shewed his
judgment; for in a few minutes she burst into violent sobbings, and
the death-like coldness of her hand gave place to a friendly
perspiration. He gave her a cordial; and ordering no one to disturb
her by speaking, I was left with her. By his orders, I neither checked
her tears, nor evaded her enquiries. I believe, however, that she
dosed for some time, as not a sigh escaped her. At length, putting
aside the curtain, she spoke, and I approached her. “Angel of mercy
and goodness,” said she, kissing my hand, “tell me, has no one seen
my distress?” “The servants saw you in a fainting state,” replied I.
“But they never saw me so ill I believe,” observed she with anxiety,
“Did nothing escape me?” I satisfied her at once on this point, and at
her request briefly, and I think wisely, informed her of the leading
events contained in the captain’s letters. She wept, and I proceeded.
“In this trial of your faith and fortitude,” said I, “it is not possible you
can overlook the merciful Being, who has secured Duncan from guilt,
by removing him to an abode of peace.” “I cannot express my
thankfulness,” replied she, “but I feel the gratitude.—But my
wretched lost brother!” She shuddered anew— “He is before an
unerring Judge,” replied I, interrupting her. “It neither becomes you
nor myself to limit infinite mercy. You are now called upon, by that
God of mercy, to submit to his power and to trust in his goodness
and compassion. Let it be your concern to perform, with courage, the
part assigned you. It has been a difficult one; but not beyond your
strength. Remember that you are still a wife, and a mother; and your
duties will give you patience and peace.”
Emulate the man in whose sorrows you have shared; “he was
faithful to the end.” Deprive him not of the glory of having loved your
reputation and your honour more than his own. To Lady Maclairn he
sacrificed his fondest hopes, his vengeance on his oppressor, his ease
in life, and even the name of her faithful Duncan to his last moments.
Weep for him! continued I, with my eyes streaming; neither religion
nor virtue forbid this tribute to his memory; but live to preserve Sir
Murdoch Maclairn’s peace. “I would die rather than disturb it,” said
she with agony. “It is my misery, my past punishment, that whilst my
soul mourns the fate of a man ruined by my affection, another not
less worthy, not less beloved has been involved in all the perils of my
miserable condition and conduct. I cannot live without Maclairn’s
esteem and tenderness; I cannot die without affecting him. I must
still wear the odious cloak of deceit; I must still impose on his noble
unsuspecting nature. Oh fatal consequences of my quitting the paths
of truth!” added she, with interrupted sighs; “wretched fruits of my
weak credulity and childish fears! Had I been firm, had I shown
myself to the world as the reprobated widow of poor Duncan, I
should long ere this have smiled at its contempt, or been at peace in
my grave. But for what am I not now answerable?” “Not for your
brother’s wickedness,” replied I eagerly, “you have a fair account, my
dear friend, to set against the errors of your youth; recollect the place
you have filled in society, the years of suffering your tender cares
have mitigated, the duties of the mother you have performed, the
happiness you have administered; and I will add, the pangs your
courage has sustained in order to effect the tranquillity of others.
Secresy is now a duty, and an obligation enforced upon you, by every
motive of virtue and utility. Let me see you, what you may be; unless,
by recalling the past, you destroy your health, and my hopes. The
storm is passed; and if you experience not the joy of an unclouded
sky, yet the evening of your days may be serene and quiet.”
She promised me to be all I wished, and to brace every nerve
against her husband’s return. I think she is more composed to day;
and at her request I have been with Miss Flint. As I expected, she
began by lamenting her ladyship’s sudden indisposition, and added,
that Percival also had a cold which prevented her seeing him. I gave
her hopes of her sister’s speedy recovery, and endeavoured to keep
up the conversation; but she soon dosed, which I find she again does
half her time, and I left her without being noticed.
Good night, I am going to bed, and to sleep if I can. Mrs. Allen will
be with Lady Maclairn. I direct my letters to Sedley. You will
understand by the accompaniments my reason for so doing. Mary
might wonder at not being trusted; Mr. Sedley will give you this
packet. Adieu. Let me know that the intelligence is secure in your
hands. My friend wishes you to keep these with the other papers: she
has read them.
I am really quite worn out with one or two night’s watching; but do
not fancy me sick, should I be lazy. We expect Sir Murdoch the day
after to-morrow; and I may have too much business on my hands to
write to you before Saturday.
LETTER LXV.
From Mr. Paget to Capt. Percival Flint.
(Enclosed in the preceding.)
DEAR SIR, Kingston, Jamaica, &c.
The melancholy contents of this letter will sufficiently account for

its being written by a stranger to you. The duty assigned to me will,
however, at once show me the friend of Mr. Flint, and the painful
witness of the distress, into which all his family are plunged.
The sudden death of Mr. Flamall, his uncle, is an event, which,
under the common circumstances of human life, would require
precaution, in the communication of it at Farefield Hall. But my
poor friend has to dread every thing, lest the catastrophe of his
uncle’s end, should reach his mother through the channel of the
public papers. He conjures you to consult his brother Malcolm in
those measures which are necessary to prevent this blow reaching
the hall too suddenly for his mother’s strength. Before I begin the
detail of those particulars, which you will naturally wish to have
before you, permit me to have the satisfaction of assuring you, that
my patient, and I may add my dearest friend, Philip Flint, is in a
degree recovered from the illness brought on by the first agitation of
his spirits; his amiable wife is well, and as yet a stranger to the
shocking tale. I will now begin my melancholy task.
The arrival of a large vessel in this port, from New York, and
commanded by a Captain Nelson, may be assigned as one of those
cases which have produced the event before me. In consequence of
Mr. Flamall’s having a concern in the cargo, he was induced to quit
his retirement; and to come to the Creek plantation, near this place.
To this circumstance I was a stranger, however, having, as Mr. Flint’s
friend, dropped a man, generally condemned for his inflexibility; and
at present forgotten by that society, which for some time he had so
carefully, and gloomily avoided.
I happened to be at the general rendezvous, a coffee-house here,
when a merchant, of the name of Gilpin, an intimate friend of mine,
entered, with Captain Nelson, the newly arrived stranger. I was
presented to him by my friend: and, in a way, which the captain and
myself both appeared to understand. I found, that Mr. Gilpin had
long known this gentleman; and in a few minutes I thought I had
long known him myself, from the frankness of his manner. We were
settling our plan for dining together; when one of the waiters told
Mr. Nelson, that “Mr. Flamall was on horseback at the door, and
wished to speak to him for a minute.” The captain instantly obeyed
the summons, and, in a few minutes, he returned to the room, and I
saw Flamall pass the window. I remarked to some one near me, that
he looked ill and dejected. The captain, was now disturbed by a more
serious business. Some one in the passage called loudly for
assistance; and the captain was told, that “his steward was in the
agonies of death in the corridor.” We flew to the spot; and, as a
medical man, it became my duty to succour the sick one. He had
been suddenly surprised, by the bursting of a large blood vessel, and
the case was critical and justly alarming. I was, however, struck by
the uncommon interest which the captain appeared to take in the
poor man’s preservation. Every accommodation the house could
afford was speedily procured; and I saw my patient in a spacious
bedroom, with a negro woman for his attendant, whom I knew was a
good nurse. Some abatement of the hæmorrhage, having succeeded
to bleeding in the arm, and other remedies, I left him to his repose;
and joined my friends at Mr. Gilpin’s, whose house was not remote
from my patient. Captain Nelson listened to my account of him with
the utmost anxiety. “I would give half I am worth,” said he, grasping
my hand, “to save this man.” This complaint came on in a moment,
they tell me: he was apparently well when I passed him; and that was
not five minutes before you saw him; those near him say it was a fit;
for they heard him groan, and he rose from his seat, as if to seek air,
when he fell back and the blood gushed from his mouth. I saw, in this
account, his hopes of the man’s recovery; which I could not
encourage, and wished not to depress.
After dinner he attended me to visit him. “I have known this man
many years,” said he. “I have no doubt of his having been
unfortunate; his education and manners speak the gentleman: his
conduct and industry the honest man. His reserve and dejection have
imposed on me a respect for his misfortunes; and to this hour I only
know, that his name is Charles, and that he is a very extraordinary
man; for his fidelity to me, has not lessened his influence with my
people; who all love him as their best friend. To-morrow morning, I
shall bring his boy on shore to be with him.” “Then he has a son?”
observed I. “One of his adoption,” answered he; “and his motives for
so doing, will give you his character. I had lost sight of him for some
years, having left him in London. In his passage from thence to New
York, where, as it appears, he was as poor as when I first saw him, he
was a common seaman: one of the crew, a native of New York fell
sick and died on the passage, recommending to Charles his aged
mother, and his child, this boy. He promised to take care of them,
and he kept his word; for taking up his abode in the old woman’s
miserable hovel, he supported the family by his labour. In this
situation, I again met him. The death of the woman, and my offer to
take the boy with him, induced him to accept the post of ship steward
on board my ship; where he has been several years. You will judge of
him as a schoolmaster, when you see George.” “Poor lad!” continued
the captain, “he will break his heart; but I will be his friend.”
I returned to my patient, but did not allow him to speak; he was
told that his George would be with him in the morning, and his hand
only was offered to the captain.
On entering the room the following day, I found George at his post.
The patient was raised by his pillows; and one of the finest youths,
my eyes ever beheld, filled the space they had left. He was bending
over the sick man, in an attitude convenient for his head to rest on
the lad’s shoulder, who was, as I judged, between fifteen and sixteen,
and in the full vigour of youth. He raised his penetrating large black
eyes to my face, whilst I made my enquiries of the woman, relative to
the condition of his father. Her replies were not unfavourable; and
never shall I forget the look of gratitude I then received! But
overcome by his sensibility, he wept most bitterly, and hid his face.
Captain Nelson entered at this moment. “Why, how is this, my boy,”
cried he endeavouring to hide his feelings, “Did you not promise to
have a good heart! The doctor will soon set us all to rights again; so
have courage.” The doctor, my dear Sir, was not so sanguine; but
recommending silence and repose took his leave: George assuring
me, that he would watch his father’s eyes, and those would tell him
what he wanted. In the evening I was with him again. All was in
order, and a silence, like death, prevailed in the room. George was
reading a French Telemachus; the patient was dosing; and the negro
woman was dismissed for some hours of needful rest. The next day I
had hopes, that my patient had a chance; but the following morning I
found, to my surprise, only the nurse with him. On enquiry, I learned
from her, that his father had sent him with a letter to the Creek
plantation. “Why did you not find a porter?” asked I. “Because he
said,” answered she, in a low whisper, “he could not die contented,
unless he knew that it was delivered to Mr. Flamall.” Though by no
means pleased with this exertion of writing, I said but little to the
sick man, contenting myself with his answer. “I shall write no more.”
I prolonged my stay, partly to supply nurse’s absence, whom I sent
for something needful, and partly to gratify my curiosity. The sick
man’s person was calculated to excite it. His physiognomy was noble;
his features regular; dark blue eyes, which, though sunk and dimmed
by his condition, were expressive of manly fortitude; his hair was of a
light chestnut colour, but in places, striped with the signs of age, for
it was even changed to nearly white; he was extremely fair; and the
paleness of death was relieved, by a lingering colour in his lips.
Observing the beauty of his teeth, I asked him his age. He replied,
that he believed he was turned of fifty. He was neatly dressed in a
blue and white cotton waistcoat and trowsers; and reclined on the
outside of the matrass. A statuary would not have wished for a more
perfect model of the human form! He was in height, I should think,
within six feet. I observed to him, that his chest was not made to
oppress his lungs; and that I flattered myself, the malady which had
so suddenly overtaken him, might have for its course, a less
dangerous source. He smiled, and said, he had never had any
tendency to consumptive symptoms; nor did he ever attribute his
want of health to a weak constitution. At this instant George entered,
covered with dust, and exhausted by heat and fatigue. He
approached the bed, and said, “I have seen Mr. Flamall, and given
your letter into his own hand.” “It is well:” replied my patient, with
an emotion that alarmed me; for I was still feeling the pulse, and
those would have betrayed it, without the suffusion which passed his
cheek. I turned towards George, and after lecturing him with
kindness, for his imprudent speed, I insisted on his leaving the room,
and laying down for some hours. A sign, from his father which he
understood, made him docile, and he retired. Soon after I left the
sick room, cautioning the nurse, neither to admit Mr. Flamall nor
any message from him or others to reach her charge; and taking
some sherbet in my hand, I sought George’s little room. He had
obeyed me, and had taken off his clothes. I told him the
consequences which would result from any exertion or surprise to his
father; warning him to be on the watch. He said, he did not believe
his father expected either a visit, or an answer from the gentleman in
question. He had told him not to wait for any orders; and had
appeared only anxious, that his own letter should reach him safely.
I proceeded to the coffee-house, where, as I expected, I met
Captain Nelson. I gave him this detail; and he thought no more of it,
I believe, for he was surrounded by busy faces; and he told me, that
he should be with Charles soon, and would meet me at Mr. Gilpin’s
before sunset.
I dined with my friend; and we were quietly conversing, when
Captain Nelson bursting into the room, said with agony, “it is all over
with him! nothing can now save him!” I waited not for more
intelligence, but seizing my hat, hastily made my way to the sick
man, Nelson following me. It was, indeed, “all over with him;” all our
care and attention availed nothing! For in a few hours he died. Poor
Nelson, during this scene of painful suspense, lamented, in terms of
the bitterest grief, that he had caused the relapse. He said, that he
had found him quiet and apparently easy. “The nurse said George
was sound asleep, and mentioned your orders,” added the captain. “I
asked Charles what were his connexions with Mr. Flamall;” he calmly
replied, that he had known him in his youth. “And was that all?”
asked I; “come, be open with me, you have had George in your head,
I dare say, and fancying to make a friend for the poor lad; but give
yourself no concern about him. Let the worst come to the worst, he
will never want a father whilst I have a guinea; so try and be a man
again, and the brother of one who loves you as a brother.” He
grasped my hand with convulsive strength. “My God!” said he aloud,
“I thank thee, and die satisfied that thou art a God, merciful and
gracious!” “The blood again gushed from his mouth; and I flew to
Gilpin’s.”
I will pass over the sorrow of his poor George, in order to hasten to
the next still more serious and shocking event. Mr. Sinclair, the
brother of my patient, Mrs. Flint, brought me a summons to
“Upland,” the residence of the family, prepared to expect hourly the
lady’s want of my assistance. I accompanied her brother home; but
found Mrs. Flint, though in her own apartment, with her female
friends, perfectly contented with my being within the house. The
interval was devoted to my friend Philip’s amusement, whose anxiety
for the safety of his wife was apparent. We were rallying him on this
subject; and drinking to the health of his expected blessing, when
Mr. Sinclair was called from the table. I will pass over the detail.
Juba, an old and freed slave of the late Mr. Cowley’s, but who has
from his master’s death remained in his post of superintendent at the
Creek house, was the bearer of the intelligence which follows; and
which you will conceive produced the most dreadful sensations of
horror and surprise. “Mr. Flamall was dead, and by his own hand!”
Sinclair and myself lost no time, in returning with Juba, leaving Mr.
Flint to the care of Mr. Lindsey, and Mr. Montrose, his friends, and
inmates.
On the road Juba gave us the following particulars. On the
preceding morning, he it was, who saw George, who enquired of him
for Mr. Flamall, saying, he had a letter to deliver to him, which he
was ordered to give to no other person. “I asked the lad from whom
he had received his commission,” continued the faithful Juba, and he
replied, from Captain Nelson’s steward. Knowing that we had many
bales in his ship, I immediately concluded, that the letter referred to
business, relative to these goods; and I was on the point of telling the
young man, that I would be answerable for the safety of the letter;
but at that moment, Mr. Flamall appeared, and took it himself. I
shall be at Kingston to day, said he, holding the letter carelessly in
his hand, and shall speak to your captain. The lad bowed, and was
retreating; when Mr. Flamall asked him to rest, and take some
refreshment. He declined the offer, replying that his father would
want him. I entered the house; and he departed. Mr. Flamall was not
long, I believe, before he went to his apartment. He saw no one for
some hours; at length he rang his bell, and ordered his horse to be
prepared. We have lately observed him as a man struggling with
something wrong in his mind. He has been very odd at times; and his
groom said, he was in one of his silent fits; and chose to go by
himself. He did not return home, till a late hour in the evening. The
horse appeared heated and fatigued. He went to his bed room,
saying, that he wanted nothing then, and should ring in the morning,
when he did. Hour succeeded hour. We heard him pacing in the
library; and we began to fear that all was not right with him. “His
servant was curious, as well as uneasy; he stopped me on the
staircase, to tell me, that he had peeped through the key hole, that
his master was in his wrapping gown and night cap, and was writing,
and with a countenance that made him tremble: another servant was
going to make his observations by the same means,” continued poor
Juba, “when the report of a pistol checked him, and appalled us all.
We burst into the room. It was too late! you will see such a corpse! I
lost not, however, my presence of mind; one look at the shattered
mangled head of the poor wretch was enough for me! But whilst
others were gazing on the scene of horror, I secured the written
papers on his desk; which I will now give you.”
Juba drew the rumpled sheets of paper from his bosom, and
presented them to Mr. Sinclair. It is needless for me to add, that the
horrid explosion, had done its work. The aim was sure!
Herewith, you have the copies of the two letters above mentioned.
Mr. Sinclair recommends caution to you in respect to their
mysterious contents.
I shall have perhaps time to add something more to this letter; but
lest I be mistaken, receive, Sir, the unfeigned regard, and sympathy
of your very humble servant,
Thomas Paget.
LETTER LXVI.
(Enclosed in Mr. Paget’s.)
To Mr. Flamall.
Shouldest thou start, Flamall, at the sight of these well known
characters, for my hand, like my heart, has but one for my purposes.
Should thy knees tremble, and the blood recede in terror from thy
cheek, bless Heaven! Hail these indications of its mercy! Thou hast
not yet outlived humanity, thou art not yet abandoned to everlasting
destruction. Be it so! Oh God, infinite in goodness, almighty in
power!
Were I certain, Flamall, that with the form of man there were yet
one single spark left unextinguished of the spirit of a man, I would
invite thee to my dying couch, for it is near thee. I would bid thee
compare it with thy nightly bed of prosperous villany. And here settle
those accounts of the guardianship and gains. Though for years in
bondage, I have been free from guilt. No parent will demand from
me a ruined oppressed son; no confederate in vice and cruelty and
treachery will point to me as the betrayer of his soul! But thou wilt
recall to memory the issue of thy crimes; and the names of thy agents
in mischief.
I die in peace. My wife knows my innocence and my wrongs. If it
be needful for thy repentance, apply to her; and with the tale of thy
brotherly care, of an innocent, and virtuous orphan-sister, thou
mayest have the relation of the woes thou hast inflicted on thy ward
Charles.
Detain not the messenger: I wait his return to breathe my last sigh
on his faithful bosom. Thou hast been defeated, Flamall! The tear of
affection will fall on my remains; and I shall be remembered as one
who has not lived to be the fell destroyer of my fellow-man, nor as
one abandoned by his Maker.
LETTER LXVII.
From Mr. Flamall to Mr. Philip Flint.
(Enclosed in Mr. Paget’s.)
Horror! unutterable horror! anguish, despair! Twist not thus my
brain! he is dead! and died with his hopes! expecting to be welcomed
in a new existence, by assembled angels, hailed by spirits like his
own, and received by a God of mercy who will recompense his long
sufferings and faith.—Delusions all! The tales of the nursery made up
for children! I reject them. When these atoms which compose this
palpitating frame are disunited I shall be at peace: for I shall be
nothing. But wherefore do I pause? What is to me the world to which
I now cleave? Why does my heart turn to thee, Philip? I know thou
also abhorrest me, yet I would not have thee curse me, for of all men,
I have a claim to thy pity. I love thee still. I would bless thee, but I
dare not. For if there be a God, whose awful indignation takes
cognizance of sin; my blessing would be converted into a malediction
on thy head. Blot me from thy memory; acknowledge not the name of
Flamall, nor permit thy children to know, that I was once thy guide,
thy friend——Nay——Distraction! Why do I hesitate——
Mr. Paget in continuation.
It is needless to make any comments on the foregoing letters. It is
but too apparent, that Flamall was the aggressor; beyond this all is
conjecture. We have, on our part, acted with caution. Captain Nelson
has been questioned closely, as to his knowledge of the person,
supposed to have been the cause of the dreadful end of Mr. Flamall.
He repeated, on oath, his evidence in favour of this unknown, and
adhered to the account he had before given me of his acquaintance
with him; adding, that he had not a doubt of his having been an
injured man. His sorrow, for his loss, was not concealed; for he even
shed tears, and with an oath affirmed, that not only himself but every
man in his ship had lost a brother. Poor George was with him, and
looked the picture of despair: he was examined also: he had never
heard his father and protector name Mr. Flamall until the morning
he gave him the letter. Not a single paper was found in his chest,
except a note, in which he gives, with his blessing, his little property
of clothes, linen, and a few books to this boy. Thus, has every enquiry
terminated. I cannot help believing, that you will be gratified by
knowing, that Captain Nelson means to protect the lad in question.
Mr. Flamall has been careful to leave no traces behind him, that
may help to elucidate this mystery, or throw a light on any other of
his private concerns. Not a paper, nor a letter escaped his vigilant
cautions. Juba tells us, that from the time his nephew’s marriage was
announced, he has suspected his mind to have been deranged at
times, and that he was continually reading and burning letters and
papers when in his room. One striking proof of his former connexion
with the unfortunate stranger, Charles, is much talked of. He called
at the house where he lodged and died; and to the enquiries he made
concerning the sick man, one of the servants answered, that he was
dead. He said, he wished to see him, having known him in his youth.
The negro woman attended him to the deceased man’s room. He
looked attentively at the corpse; appeared agitated, and sighing said,
“his troubles are over.” But such was the impression the object before
him had produced, that he left the house, and forgot his horse, which
he had tied to the door he had passed. A waiter perceiving it,
followed him with the animal; he mounting, and without speaking,
put him on his full speed.
Thomas Paget.

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(eBook PDF) Medical-Surgical Nursing:

Clinical Reasoning in Patient Care

Library of Congress Cataloging-in-Publication Data

LeMone, Priscilla, author.

Musculoskeletal Metabolic Processes

Focus on Cultural Diversity

Acute Pain and Associated Manifestations

Anxiety, fear Emotional responses to pain stimuli generated by limbic system.

manifestations OF DISORDERS MANIFESTATIONS OF IMPENDING DEATH

Nursing Care of the Patient NURSING CARE OF THE PATIENT

Increased Intracranial Pressure

Evidence for Nursing Care

PRACTICE ALERT! alerts

Moving Evidence into Action

Moving Evidence into Action

Case Study & Nursing Care Plan

CASE STUDY & NURSING CARE PLAN A Patient with Gonorrhea

End of Unit clinical scenario

Clinical Reasoning/Judgment in the Interprofessional Care 56

Disease and Illness 35 Interprofessional Care 105

of Health 135 Interprofessional Care 194

Acid–Base Disorders 213 Chapter 13 Nursing Care of Patients

Nursing Care 224 Interprofessional Care 307

Interprofessional Care 235 Interprofessional Care 320

Assessing the Integumentary The Patient with Actinic Keratosis 409

Nursing Care 483 Vitamins 540

Nursing Care 608 Interprofessional Care 647

My dear and honoured friend! It is all over with Jeremiah Serge!

My letter[1] of Monday last contained the intelligence of the good

DEAR SIR, Kingston, Jamaica, &c.

The melancholy contents of this letter will sufficiently account for

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