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iv CONTRIBUTORS
Patricia A. O’Connor, RN, MSN, CNE
Assistant Professor
College of Nursing
Saint Francis Medical Center College of
Nursing
Peoria, Illinois
Jill Parsons, PhD, RN
Associate Professor of Nursing
MacMurray College
Jacksonville, Illinois
Beverly J. Reynolds, RN, EdD, CNE
Professor
Graduate Program
Saint Francis Medical Center College of
Nursing
Peoria, Illinois
Kristine Rose, BSN, MSN
Assistant Professor
Nursing Education
Saint Francis Medical Center College of
Nursing
Peoria, Illinois
CONTRIBUTORS TO PREVIOUS EDITIONS
Jeanette Adams, PhD, MSN, APRN, CRNI
Paulette M. Archer, RN, EdD
Myra. A. Aud, PhD, RN
Marjorie Baier, PhD, RN
Sylvia K. Baird, RN, BSN, MM
Karen Balakas, PhD, RN, CNE
Lois Bentler-Lampe, RN, MS
Janice Boundy, RN, PhD
Anna Brock, PhD, MSN, MEd, BSN
Sheryl Buckner, RN-BC, MS, CNE
Jeri Burger, PhD, RN
Linda Cason, MSN, RN-BC, NE-BC,
CNRN
Pamela L. Cherry, RN, BSN, MSN, DNSc
Rhonda W. Comrie, PhD, RN, CNE, AE-C
Eileen Costantinou, MSN, RN
Ruth M. Curchoe, RN, MSN, CIC
Marinetta DeMoss, RN, MSN
Christine R. Durbin, PhD, JD, RN
Martha Keene Elkin, RN, MS, IBCLC
Patsy L. Ruchala, DNSc, RN
Professor and Director
Orvis School of Nursing
University of Nevada, Reno
Reno, Nevada
Matthew R. Sorenson, PhD, APN, ANP-C
Associate Professor/Associate Director
School of Nursing
DePaul University
Chicago, Illinois;
Clinical Scholar
Physical Medicine and Rehabilitation
Northwestern University Feinberg School of
Medicine
Chicago, Illinois
Leah W. Frederick, MS, RN CIC
Mimi Hirshberg, RN, MSN
Steve Kilkus, RN, MSN
Judith Ann Kilpatrick, RN, DNSc
Lori Klingman, MSN, RN
Karen Korem, RN-BC, MA
Anahid Kulwicki, RN, DNS, FAAN
Joyce Larson, PhD, MS, RN
Kristine M. L’Ecuyer, RN, MSN, CCNS
Ruth Ludwick, BSN, MSN, PhD, RNC
Annette G. Lueckenotte, MS, RN, BC,
GNP, GCNS
Frank Lyerla, PhD, RN
Deborah Marshall, MSN
Barbara Maxwell, RN, BSN, MS, MSN,
CNS
Elaine K. Neel, RN, BSN, MSN
Wendy Ostendorf, BSN, MS, EdD
Dula Pacquiao, BSN, MA, EdD
Nancy C. Panthofer, RN, MSN
Donna L. Thompson, MSN, CRNP,
FNP-BC, CCCN-AP
Continence Nurse Practitioner
Division of Urogynecology
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania;
Continence Nurse Practitioner
Urology Health Specialist
Drexel Hill, Pennsylvania;
Continence Consultant/Owner
Continence Solutions, LLC
Media, Pennsylvania
Jelena Todic, MSW, LCSW
Doctoral Student
Social Work
University of Texas at Austin
Austin, Texas
Elaine U. Polan, RNC, BSN, MS
Debbie Sanazaro, RN, MSN, GNP
Marilyn Schallom, RN, MSN, CCRN,
CCNS
Carrie Sona, RN, MSN, CCRN, ACNS,
CCNS
Marshelle Thobaben, RN, MS, PHN,
APNP, FNP
Ann B. Tritak, EdD, MA, BSN, RN
Janis Waite, RN, MSN, EdD
Mary Ann Wehmer, RN, MSN, CNOR
Pamela Becker Weilitz, RN, MSN(R), BC,
ANP, M-SCNS
Joan Domigan Wentz, BSN, MSN
Katherine West, BSN, MSEd, CIC
Terry L. Wood, PhD, RN, CNE
Rita Wunderlich, PhD, RN
Valerie Yancey, PhD, RN

Colleen Andreoni, DNP, FNP-BC, ANP-BC,
CEN
Assistant Professor and Department Chair
Health Promotion & Risk Reduction
Marcella Niehoff School of Nursing
Loyola University Chicago
Chicago, Illinois
Suzanne L. Bailey, PMHCNS-BC, CNE
Associate Professor of Nursing
University of Evansville
Evansville, Indiana
Lisa Boggs, BSN, RN
ER Staff Nurse
Mercy Hospital
Lebanon, Missouri;
Teaching Assistant
Sinclair School of Nursing
University of Missouri—Columbia
Columbia, Missouri
Leigh Ann Bonney, PhD, RN, CCRN
Assistant Professor
College of Nursing
Saint Francis Medical Center College of
Nursing
Peoria, Illinois
Anna M. Bruch, RN, MSN
Nursing Professor
Illinois Valley Community College
Oglesby, Illinois
Jeanie Burt, MSN, MA, CNE
Carr College of Nursing
Harding University
Searcy, Arkansas
Pat Callard, DNP, RN, CNL, CNE
Assistant Professor of Nursing
College of Graduate Nursing;
Director
Interprofessional Education, Phase II
Pomona, California
Susan M.S. Carlson, MS, RN, APRN-BC,
NPP
Associate Professor
Monroe Community College
Rochester, New York
Tracy Colburn, MSN, RN, C-EFM
Assistant Professor of Nursing
Lewis and Clark Community College
Godfrey, Illinois
Barbara Coles, PhD(c), RN-BC
Registered Nurse
James A. Haley VA Hospital
University of South Florida
Tampa, Florida
Dorothy Diaz, MSN, RN-BC
Caregiver Support Coordinator
James A. Haley VA Hospital
Tampa, Florida
Holly J. Diesel, PhD, RN
Associate Professor
Goldfarb School of Nursing
Barnes-Jewish College
St. Louis, Missouri
Dawna Egelhoff, MSN, RN
Associate Professor
Lewis and Clark Community College
Godfrey, Illinois
Amber Essman, MSN, APRN, FNP-BC,
CNE
Assistant Professor
Chamberlain College of Nursing
Columbus, Ohio
Margie L. Francisco, EdD, MSN
Nursing Professor
Illinois Valley Community College
Oglesby, Illinois
Linda Garner, PhD, RN, CHES
Assistant Professor
Department of Nursing
Southeast Missouri State University
Cape Girardeau, Missouri
Amy S. Hamlin, PhD, MSN, FNP-BC, APN
Professor of Nursing
Austin Peay State University
Clarksville, Tennessee
Nicole M. Heimgartner, RN, MSN, COI
Associate Professor of Nursing
Kettering College
Kettering, Ohio
Mary Ann Jessee, MSN, RN
Assistant Professor
School of Nursing
Vanderbilt University
Nashville, Tennessee
Kathleen C. Jones, MSN, RN, CNS
Associate Professor of Nursing
Walters State Community College
Morristown, Tennessee
REVIEWERS
Lori L. Kelley, RN, MSN, MBA
Associate Professor of Nursing
Aquinas College
Nashville, Tennessee
Shari Kist, PhD, RN, CNE
Assistant Professor
Goldfarb School of Nursing
Barnes-Jewish College
St. Louis, Missouri
Laura Szopo Martin, MSN, RN, CNE
Professor
College of Southern Nevada
Las Vegas, Nevada
Angela McConachie, DNP, FNP-C
Instructor
Goldfarb School of Nursing
Barnes-Jewish College
St. Louis, Missouri
Tammy McConnell, MSN, APRN, FNP-BC
Associate Professor of Nursing
Admission and Progression Coordinator
Clinical Coordinator
Greenville Technical College
Greenville, South Carolina
Janis Longfield McMillan, RN, MSN, CNE
Nursing Faculty
Coconino Community College
Flagstaff, Arizona
Pamela S. Merida, MSN, RN
Assistant Professor, Nursing
St. Elizabeth School of Nursing
Lafayette, Indiana
Jeanie Mitchel, RN, MSN, MA
Nursing Professor
South Suburban College
South Holland, Illinois
Katrin Moskowitz, BSN, MSN, FNP
Family Nurse Practitioner
Bristol Hospital Multispecialty Group
Bristol, Connecticut
Cindy Mulder, RNC, MS, MSN, WHNP-BC,
FNP-BC
Instructor
The University of South Dakota
Vermillion, South Dakota
v
vi REVIEWERS
Cathlin Buckingham Poronsky, PhD,
APRN, FNP-BC
Assistant Professor
Director of the Family Nurse Practitioner
Program
Marcella Niehoff School of Nursing
Loyola University Chicago
Chicago, Illinois
Beth Hogan Quigley, MSN, RN, CRNP
Family and Community Health Department
Advanced Senior Lecturer
University of Pennsylvania School of
Nursing
Philadelphia, Pennsylvania
Cherie R. Rebar, PhD, MBA, RN, FNP, COI
Director, Division of Nursing
Chair, Prelicensure Nursing Programs
Professor
Kettering College
Kettering, Ohio
Anita K. Reed, MSN, RN
Department Chair
Adult and Community Health Practice
St. Elizabeth School of Nursing
Saint Joseph’s College
Lafayette, Indiana
Rhonda J. Reed, MSN, RN, CRRN
Learning Resource Center Director—
Technology Coordinator
Indiana State University
Terre Haute, Indiana
Carol A. Rueter, RN, PhD(c)
Bereavement Coordinator/Clinical
Instructor
James A. Haley VA Hospital
University of South Florida
Tampa, Florida
Susan Parnell Scholtz, RN, PhD
Associate Professor of Nursing
Moravian College
Bethlehem, Pennsylvania
Gale P. Sewell, PhD(c), MSN, RN, CNE
Associate Professor
University of Northwestern
St. Paul, Minneapolis
Cynthia M. Sheppard, RN, MSN, APN-BC
Assistant Professor of Nursing
Schoolcraft College
Livonia, Michigan
Elaine R. Shingleton, RN, MSN, OCN
Service Unit Manager, Oncology/Infusion
The Permanente Medical Group
Walnut Creek, California
Crystal D. Slaughter, DNP, APN, ACNS-BC
Assistant Professor
College of Nursing
Saint Francis Medical Center College of
Nursing
Peoria, Illinois
Mindy Stayner, RN, MSN, PhD
Professor
Northwest State Community College
Archbold, Ohio
Laura M. Streeter
Coordinator, Clinical Simulation Learning
Center
University of Missouri—Columbia
Columbia, Missouri
Estella J. Wetzel, MSN, APRN, FNP-C
Family Nurse Practitioner
Integrated Care
Scioto Paint Valley Mental Health Clinic
Chillicothe, Ohio;
Clark State Community College
Springfield, Ohio
Laura M. Willis, MSN, RN, FNP
Assistant Professor
Coordinator of Service Learning
Kettering College
Kettering, Ohio
Lea Wood, MSN, BSN-RN
Coordinator, Clinical Simulation Learning
Center
University of Missouri—Columbia
Columbia, Missouri
Damien Zsiros, MSN, RN, CNE, CRNP
The Pennsylvania State University
Lemont Furnace, Pennsylvania
I have been incredibly fortunate to have a career that has allowed me to develop
long-lasting friendships with amazing professional nurses. I dedicate this book to
one of those amazing nurses, Coreen Vlodarchyk. She is the consummate nurse
and leader who has allowed me to pursue a different direction in my career,
offering her enthusiastic and unfettered support.
Patricia A. Potter

To all nursing faculty and professional nurses who work each day to advance
clinical nursing. Your commitment to nursing education and nursing practice
inspires us all to be the guardians of the discipline. I also want to acknowledge all
the reviewers and contributors to this text. A great thank you goes out to my
coauthors. Together we challenge, encourage, and support one another to produce
the best textbook.

I also want to thank my family for their loving support. A special thank you to
my grandchildren, Cora Elizabeth Bryan, Amalie Mary Bryan, Shepherd Charles
Bryan, and Noelle Anne Bryan, who always tell it like it is.
Anne Griffin Perry

To my husband, Drake, and daughters, Sara and Kelsey. Thank you for your love
and patience as I have spent time writing, reviewing, and editing for this edition
of Fundamentals. Your support has made this endeavor possible for me! And to all
the nurses and nursing faculty, especially the faculty at Saint Francis Medical
Center College of Nursing. Thank you for all your hard work, caring, compassion,
and presence as you work with patients and nursing students on a daily basis.
Your commitment to nursing and nursing education is the foundation that makes
nurses the most trusted professionals!
Patricia A. Stockert

To Debbie, Suzanne, Melissa, Donna, Joan, Cindy, Jerrilee, Theresa, and Kathy.
Your never-ending enthusiasm for helping to shape the nurses of our future inspire
me all the time. I value your friendship and support. To Patti, Anne, and Pat for
your friendship, support, and quest for excellence. And to Greg, the love of my life,
for supporting and encouraging me to spread my wings and grow both personally
and professionally.
Amy M. Hall
S T U D E N T P R E FAC E

Fundamentals of Nursing provides you with all of the fundamental

nursing concepts and skills you will need as a beginning nurse in a
visually appealing, easy-to-use format. We know how busy you are and
how precious your time is. As you begin your nursing education, it is
very important that you have a resource that includes all the informa-
32
tion you need to prepare for lectures, classroom activities, clinical
Medication A
assignments, and exams—and nothing more. We’ve written this text OBJECTIV
dministratio n
ES
to meet all of those needs. This book was designed to help you succeed • Discuss nursing
administration.
roles and responsi
bilities in med
ication
in this course and prepare you for more advanced study. In addition • Describe the
• Differentiate
physiological mec
among different
hanisms of med
ication action.
• Implement
nursing actions
• Describe facto
rs to consider
to prevent med
ication errors.
types of medicati when choosing
to the readable writing style and abundance of full-color photographs • Discuss deve
• Discuss facto
lopmental facto
rs that influence
rs that influence
on actions.
pharmacokineti
administration.
• Calculate pres
cribed medicati
routes of medicati
on
• Discuss met medication actio cs. • Discuss facto on doses correctly
and drawings, we’ve incorporated numerous features to help you study medications.
hods used to educ
ate patients abou
ns.
t prescribed
rs to include in
response to med assessing a pati
ication therapy.
.
ent’s needs for
and
• Compare and • Identify the
six rights of med
and learn. We have made it easy for you to pull out important content. pharmacist, and
contrast the role
s of the health
nurse in medicati care provider,
on administratio
them in clinical
• Correctly and
settings.
ication administ
ration and app
ly
n. safely prepare
Check out the following special learning aids: KEY TERM
S
Absorption, p.
and administer
medications.
611
Adverse effects, Intraocular, p.
p. 613 617
Anaphylactic reac Intravenous (IV)
tions, p. 613 , p. 615 Pressurized met
Biological half Irrigations, p. ered-dose inha
-life, p. 614 618 (pMDIs), p. 638 lers
Biotransformatio Medication aller
n, p. 612 gy, p. 613 Side effects, p.
Buccal, p. 615 Medication erro 613
Solution, p. 618
Learning Objectives begin each chapter to help you Detoxify, p. 612
Idiosyncratic reac
tion, p. 613
Medication inte
Medication reco
r, p. 624
raction, p. 613 Subcutaneous,
p. 615
Sublingual, p.
focus on the key information that follows. Infusions, p. 614 nciliation, p. 625 615
Metric system, Synergistic effe
Injection, p. 611 p. 617 ct, p. 613
Nurse Practice Therapeutic effe
Instillation, p. Acts (NPAs), p. ct, p. 613
617 Ophthalmic, p. 610
638 Toxic effects, p.
Intraarticular, 613
Key Terms are listed at the beginning of each chapter and Intracardiac, p.
p. 616
616
Parenteral adm
Peak, p. 614
inistration, p.
615
Transdermal disk
Trough, p. 614
, p. 616
Intradermal (ID)
are boldfaced in the text. Page numbers help you quickly , p. 615 Pharmacokineti Verbal order, p.
Intramuscular cs, p. 611 621
(IM), p. 615 Polypharmacy, Z-track method
p. 633 , p. 650
Prescriptions,
find where each term is defined. MEDIA RESO
URCES
http://evolve.else
p. 623

vier.com/Potter/f
• Review Que undamentals/
stions
Evolve Resources sections detail what electronic • Video Clips
• Concept Map
Creator
• Skills Perform
• Audio Glos
ance Checklists
sary
resources are available to you for every chapter.
• Case Study • Calculations
with Question Tutorial
s • Content Upd
ates

Patients with heal

th pro
problems use a
maintain their variety of strat
health. One strat egies to restore
substance used egy they often or medications and
in the d
diagnosis, trea use is medicati side
of health prob tment, cure, relie on, a regimen, and eval effects, encouraging adheren
707 lems. No m mat ter whe f, or prevention uating the pati ce to the medicati
lf-Conc ept hospitals, clini
cs, or home), nurs re patients receive health care administer med
ications.
ent’s and family
caregiver’s abili
on
R 34 Se
administering, es play an esse (i.e., ty to
CHAPTE
and evaluating ntial role in prep
members, frien the effects of aring,
ir wounds
and scars, ds, or home care medications. Fam SCIENTIFIC KN
ers to the the tions when pati
ents cannot adm
personnel ofte
n adm
ily OWLEDGE BASE
ons of oth nses toward all settings nurs inister them them inister medica-
y wa tch the reacti are of your respo ely” or “This es are responsi selves at home. Because medicati
on administratio
sel aw ble for evaluati
Patients clo y important to be healing nic the patient. tions on the pati ng the effects of In of nursing prac n and evaluati
wound is of ent’s ongooing health statu medica- tice, nurses need on are a critical
an d it is ver h as, “This bo dy image tie nt s, teaching him of all medicati to understand part
ACTICE temen ts suc the a pa or her about ons taken by thei the actions and
ons for sts for
ASED PR
effects
patient. Sta althy” are affirmati el of caring that exi acknowledge safely requires r patients. Adm
ENCE-B an understandin inistering med
ks he
-4 EVID vey the lev rsonal reactions,
ent ications
Adolesc tissue loo viors con task or situ
- g of legal aspe
BOX 34 on be ha te pe nt cts of health
ct al ipa asa
the Impa Nonv erb . An tic the un ple orate care,
ept and self-esteem instead of ation incorp
Self-Conc haviors ors in at-risk and affect on the patient in the patient’s situ d denial.
Drinking
Be drinking beh
avi
them, and
foc us
put thems
elves , an
ation, anger propriate treat-
609
pt influence rses who ent, frustr
s self-conce ation. Nu barrassm on, and
ap
tential
ion: How doe to ease em identificati and the po self-
PICO Quest measures res, early stressors
ts? tive measu self-esteem cific
adolescen t drin kin g Pre ven sity of to design spe is
tiva te adolescen se nim ize the inten he r fam ily. Learn ris k factors. It
ary n mo that increa ment mi or of rk col-
Evidenc
e Summ perhaps eve in behaviors a patient
and his
a patient’
s profile m and wo
precede or lthy
sel f-co ncept may e ma ny teens engage th dev elop a hea effects for
erv en tio ns to fit pti on of a proble ns designed to
Low
al., 2013).
Becaus helping you king (CDC,
rce
concept int ess a patient’s pe t issues. Interventio for prevent-
(Dudovitz et mortality, ing teen drin
rbidity and ors, includ 9% essential
to ass self-concep ing may be benefic
ial
ial for mo risk behavi drinking; 34. to resolve ting chron
ic dis-
the potent vent health ts reported laboratively
hy eat
pt may pre ool studen (CDC, 2014). and healt em, preven
self-conce thir ds of high sch ors ed bin ge drinking s wa s mo te active living improving self-este ulthood.
3 two 8% end ale pro
2014). In 201 alcohol use, and 20. bot h ma les and fem dents. ild ho od obesity,
h ou tco me s in ad
rent king in ck stu ing ch g healt
reported cur valence of current drin and then bla drinking- improvin
pre by Hispanic, g eases, and TIENT-IN PA
Overall the students, foll
owed en creatin
ortant wh skills ENCY feels inse-
higher am
ong white tors is imp munication COMPET dent who
tective fac to learn com an adolescent ILDING nursing stu
Identifying
prevention
risk and pro
pro gra ms . Enhancing
behaviors
opportunities
ma y ma ke drinking les
s of QSEN QS
CE NTERED
EN: BU
CA RE . You are a
You
third-year
are caring
for Mr s. Johnson wh
e
o had a bila
of patient,
teral
and you hop
e Evidence-Based Practice boxes summarize the results
rna tive set ting . this typ r patient
clinical
of a research study and indicate how that research can be
in alte e caring for about you
and engage cure in the r firs t tim stio ns you
or. . This is you ask you que faculty approaches;
risk behavi imp rov- ma ste cto my
tructo r wo n’t
igned interact-
actice ement and clinical ins en your ass y” to avoid
rsing Pr stress manag that your
Applicatio
n to Nu
prevention
efforts sho
uld include
and adoles
cent coping because you
“forget” eve
rassed tha
rything wh
es “hide”
t you sometim r, “How can I att
or “look bus
end to my
patient’s
I can’t eve
n deal
applied to nursing practice.
• Drinking- . nt of child n, con- feel embar r. You wo
nde ues when
f-e ste em ass ess me mu nic atio ins tru cto ste em iss ste em and
ing sel
sin g action is
the
inc lud e effective com 3). ing with your f-co nce pt and self-e imp rov e your self-e
nur sel to
techniques st you take
• A priority
strategies
. Ap pro pria te
ss managem
ent (Du dov itz et al., 201
ers should
tion, and stre and health care provid the use of protective
instill stu den ts’ phy sic al care and
with my ow
n?” Which
act ion
dent nurse?
s mu
Evolve we
bsite.
Building Competency scenario boxes focus on one of the
flict resolu pt as a stu nd on the
• Familie
tur al prid e, which
chers,
s, peers, tea promotes self-conce
ors suc h
pt and
as drinking. iss ues to addres
s
self-conce
Answers
to QSEN
Activities
can be fou
six QSEN key competencies and provide a short case study
cul
inst risk beh
avi important
factors are
factors aga
social, and
behavioral
lescence. , including
genetic
ge, experi
- and question.
• Family,
adolescen
ce and ado alcohol use
y, needs to
be a THINKING of knowled thinking
during pre fac tor s for early
drug and
cul tural identit CRITICAL requires a
synthesis s, critical
g risk
• Identifyin n, family environme
nt, and al thinking nts and familie nic al judg-
The 5-step Nursing Process provides a consistent
4). cri tic pa tie s. Cli
predispositio (CDC, 201 Successful red from nal stand
ard
data, and
e providers ation gathe professio alyze the
health car ence, inform intellectual and ation, an nt con-
priority for tients and s, and ipate inform g assessme

to convey
a nonjudg
mental att
itude tow
ard pa
self-
attitude
ments req
uire you
ions regard
to antic
ing your
patient’s
ild toward
care. Durin
making an
appropriate
nursing
framework for presentation of content in clinical chapters.
• Ability ences in make decis nts that bu knowledge
cu ltu ral differ ele me int egrate
families itudes tow
ard sider all is essentia
l to ory,
ceived att ction are oncept the -
• Precon e or fun diagnosis. oncept, it ing self-c vel
d self-este
em appearanc alth e of self-c disciplines, includ of cultural and de
concept an in body s of the he l In the cas d other sideration with self-
a change al response es a mode nursing an nciples, and a con for patients foundly
pa tie nts with ba l an d nonverb e pro vid fro m in car ing
Some siti ve to the
ver
ap pro ach to car yo u ob serve a mu nication pri vious experience Sel f-concept pro
extremely
sen
matter-of-f
act
mple, wh
en com car e. proach
nt to factors. Pre ividualize critical thinking ap
A positive, ily to follow. For exa and allow the patie by opmental lps to ind
care team. fam r, note it patients erations he ponse to illness. A
tient and nt’s behavio t effect on f-concept concept alt n’s res
for the pa a pa tie nifi can a pe rso
ange in have a sig ing sel influences
positive ch . Nurses ce. Includ e patient out- essential.
its meaning erest and acceptan uenc to care is
establish int e can infl p that
genuine ery of car relationshi in your
conveying planning and deliv rse-patient -making PROCESS approach
NURSING
stin g nu cis ion thinking -
issues in
the
ilding a tru d family in the
de ze a critical al decision
sitively. Bu individuali s and use es a clinic zed
comes po th the patient an f-esteem. You can d incorpo- the nu rsing proces ng pro cess provid nt an individuali
tes bo and sel e needs an l expres- Apply . The nu
rsi d impleme until the patient’s
incorpora nces self-concept s un iqu pa tie nts vel op an
ha a patient’ spiritua care of you to de tinuous
process en hlighting thods of viders proach for cess is con
ach by hig care practices or me t health care pro making ap nursing pro intained.
your appro alth nt tha patient e. Use of the , restored, or ma
ernative he care. It is importa uality affect plan of car proved
rating alt pla n of ste em and sex on cept is im
sion into
the
e to which
sel f-e sel f-c nt and
d the degre image. Fo
r each patie
understan nt’s body nt ghly assess patient-centered
cantly aff
ects a patie my is posi-
a mastecto scar. On Assessme essment process thorou t you ma
ke
outcomes. ng car e sig nifi fol low ing the ass en sur e tha
Your nursi a woman stectomy During dings to
image of of the ma expres- analyze fin
the body acceptance or disgusted facial critically
example, showing cked dy image
.
uenced by o has a sho ing a negative bo
tively infl , a nurse wh vel op
ha nd n de
the other the woma
butes to
sion contri

viii
 STUDENT PREFACE ix

Cultural Aspects of Care boxes prepare you to care for

patients of diverse populations. associated
wi
Adolescenc th shifts to more CHAPTE
e rea
levels of sel is a time of marke listic information R 34 Se
f-esteem d maturati about the lf-Concep
adulthood that
(Maldonad set the stage for ris al changes and shi
on self. t
Erikson’s o et al., 20 es in self-c fting BOX 34 703
emphasis 13 ). on cept in yo -2 CU
11) explai
ns the ris on the generativ un g Pr omoting LT UR AL ASPE
individual e in self-e ity stage Se lf- Co CT S
foc steem (1963) Diverse
Patients
ncept an OF CARE
work while uses on being inc and self-concept in (see Chapter d Self-Es
teem in
at the sam rea adulthood Culturally
tion. On e time pro singly productive . The Cultural ide
the moting an and creati ntity is an
self-concep basis of Erikson’s d guiding ve self-esteem important
t in later stages of the next gen at . Early in
growth and
component
of a
identity wit
development person’s self-concept
promotio adulthood developme era
n and a shi reflects a nt, a declin - hin the con
and
view of sel ft in self-c diminishe e aspects of text of fam an individ
f. oncept to d need for in his or her ily. As an ual develo
caused in Many report a de a more mo self- cultural exp self-conce
pt are rein
individual
matures, the
ps this
part by ph cline in sel dest and eriences. In forced thr
aging, bu
t older ad ysical and emotion steem in later ad
f-e balanced questioned
through pol
addition, a
person’s sel ough social, cultural
ult al ult home, sch itic al, social, f-co fam ily, or
logical we s with sel changes ho ncept is stre
ll-b f-concept associated od ool, and wo or cultural ngthened
aging is ass eing (Diehl and Ha
Focus on Older Adults boxes prepare you to address the
clarity de with modeling, rkplace env influences or
oci y, monstrat identity, and ironments experience
must focus ated with deterior 2011; Touhy and e psycho- self-esteem past experie
nce
. Positive or d
negative cul in the
on health ation of he Jett, 2014
). When (Rh ea and Tha s influence sel tural role
concept (W be alth, nursi tcher, 201 f-care, self-co
special needs of older adults. to addre
essential.
urm et al., havior changes to
ss the un 2013). Identifying
ique need spe
promote
ng interv
self-care
and
entions Implicatio
• Develop
ns for Pa
tient-Cen
3). ncept, and

s of patie cific nursing interv self- an open,

nonrestric
tered Ca
re
nts at var entions cultural pra tive attitud
ious life ctices to imp e for assess
Compponen stages is • Understa rove patien ing and enc
ts and Inte nd that the
relation
ts’ self-co
ncept. ouraging
A positi sit ve sel rrelated Te support can
facilitate the ship among self-este
sistency to f-concept gives a rms of Se effective em, stress,
a person. sen se of mean lf- Co ncept cop ing in cul
development
of nursing and social
ity, whic A he alt ing 2013). turally div stra teg
ich genera hy self-concep , wh oleness, an ers e adolescen ies to promote
sel
elff-c tes positi t has a hig d con- • Ask pat ts (Rhea
-co onnccept are ve feelings h degree ients what and Thatch
identity, bo toward sel they think er,
CHAPTER 36 Spiritual
ho ow w one thi
nks abou dy image f. The com of stabil- a stronger
sense of sel is important
to help the
, and role po • Encourage f.
Health 745 abboou utt oneself t on performan nents of m feel bet
(self-esteem eself (self-concep ce. Because and offerin
cultural ide
ntity and prid ter or gain
TABLE 36-2 Relig ), both con t) affects g tre e by
ious Dietary Regulation cepts need ho w one fee • Facilita atm ent choice ind ividualizin
Affecting Health Care s BOX 36-5 FOCUS IIde
deennti
de nt tty. Ide to be eva ls te culturally s to meet g
patients’ sel self-care practices
ON OLDER ADULTS wh ntity inv luated. at-risk beh sensitive f-concept
ho olelenneess
ss,, and con olves the aviors identifi health pro needs.
Spirituality and Spirit sisten internal drinking, eat ed through motion act
ations. It ivities tha
Religion Dietary Practices ual Health implies be cy of a person ov sense of
individuali and
ing disord
er
evidence-bas
ed t address
“on neese ing er time and ty, violent vid risk s, prematur pra ctic
Hinduism • There is an association
between an older adult’s spiritua
sellff ” or liv
ing an au
distinct an
d separa in differen eo gaming e sexual exp e (e.g., smoking,
learn cultu t situ- (Dudovitz eriences,
Some sects are vegetarians.
The belief is not to kill ability to adjust or cope with lity and his or her r ly accep thentic life is the ba
ral te from
oth ers. Be et al., 201
3). excessive
illness and other life stressor cation ted value sis of true
any living creature. 2014). s (Manning, on and mo m deling. s, behavio identity. Ch ing
and from Th rs, an ild
Buddhism Some are vegetarians and • Older adults achieve spiritua what indivi ey often gain an ide d roles through ide ren neighborho
do not use alcohol. Many l resilience through frequen paren duals tell ntity from nti od
fast on Holy Days. gratitude (e.g., via prayer, t expressions of ntitinngg fig them. An self-observa fi- an individu s often conceptua
meditation, or discussions peerss.. Relat ures and later with individual tions al who exp lizes
Islam finding ways to maintain purpose with friends) and ion
io ships other role first identi
fie eriences bet himself or herself
Consumption of pork and alcohol in life (e.g., helping family, com bined eff wi th parents, mo dels such s wi th ter living differently
is prohibited. (Manning, 2014). volunteering) e
ect teachers, as Bo dy condition than
Followers fast during the month self-ccononcept (V
s on young ch and peers tea ch ers or Image. Bo s.
of Ramadan. • Patients use spiritual rituals, ers ild ren ’s general, aca ha ve un ique and inc lud ing dy im ag e involves
Judaism Some observe the kosher dietary exercise, and complementary must be ab chueren
et physical ap
cope with pain and chronic medicin e to le to al., 20 12). To for de mi c, and soc bo dy pe ara att itu de s related
restrictions (e.g., illness. a coherent, bring tog
eth ial image inc nce, struc
tur to
avoid pork and shellfish, do er lea rned be m an identity, lin lud e tho e, or the bo
not prepare and eat • Feelings of connectedness consis ity, youth se related fun dy,
milk and meat at same time). are important for the older Th hee achiev tent, and unique wh haviors and expect a child fulness, he to sexuality ction. Feelings ab
Berglund, 2010). Enhance adult (Anderberg and always con alth, and , femininit out
connectedness by helping ships becau eement of identi ole (Eriks ations int sis strength. y and ma
Christianity Some Baptists, Evangelicals, meaning and purpose in life older patients find se ind
in ividuals ty is ne on, 1963). o ance. Some tent with a person’s These me
ntal image scu-
and Pentecostals by listening actively to concern
s and being
(Stuart, t, 2013). Sex express ide cessary for intim such as the
body image actual ph
ysical struc s are not
discourage use of alcohol present. Se ua lity is a pa nti ty in relation ate relati dis tor tio ture or ap
and caffeine. the lifee spa rt of identi ships with on-
eating dis ns have de pe
n. For exa as a result order anore ep psych
Some Roman Catholics fast
on Ash Wednesday and
• Beliefs in the afterlife
increase as adults age. Make creation n to compa mple, as an adult
ty, and its others of xia nervo ological ori ar-
visits from clergy, focus differ part. Be aw situational events sa. gins
Good Friday. Some do not
eat meat on Fridays social workers, lawyers, and
financial advisors available sure seeeekkin
nionship,
physical an
ages the foc
us shifts fro across
s are that mo such as the Other alterations
during Lent. as though they have complet so patients feel ingg T u dissatisfa st men an loss or ch occur
ed all unfinished business. private vie (To uhy and
Jet t, 2014).
d emotion
al int
m pro- ction with
their bodie d wo me n an ge in a body
Jehovah’s (e.g., oral history, art, photogr Leaving a legacy w of ma m leness Gender ide imacy, and plea- self-concep experience
Members avoid food prepare aphs) to loved ones prepare or femini or t. Ind ividuals oft s, wh ich affects bo som e degree of
Witnesses d with or containing to leave the world with a s an older adult ninnee behaavio femalene ntity is a when a ch en exagge dy image
v r exhibi ss; gende
blood. sense of meaning and maintai on cultu ura
rallly ted r role is the person’s body and
ange in he
alth status rate dis and overa
Mormonism tinue connection for the one
left behind (Touhy and Jett,
ns a way to con-
Cultu
ly determi m ned val . This image and masculin
e the feedb occurs. Th turbances in body ll
Members abstain from alcohol ura
rall differen ues (see Ch its ack offere e way oth image
and caffeine. • Older-adult caregivers use
their spirituality and spiritua
2012).
develops ces in ide apters 9 an meaning depend controllin
g, violent d are als ers view a
Russian Orthodox Followers observe fast days l behavio fro m nti ty d 22 ). on e hu sba o infl ue pe rson’s
and a “no-meat” rule on tices to help them deal with rs or prac- group an iden ntification exi st (Box 34 else would nd tells his wi ntial. For
Church crisis and conflict (Strudw nd d thr an d -2) . Cu thi wa nt he fe tha exa mp le,
Wednesdays and Fridays. ick and Morris, socializa ltural ide s devalua r. Over the t she is ug
During Lent all animal 2010). viduals ou ough the t experi
ence of int tion within an est ntity tion into years of ma ly and tha a
products, including dairy product tsid Cognitive her self-c rriage she t no
tural identi e the gro g up int egr
o one’s sel ating the response
ablished oncept.
s and butter, are ty Normal de growth and physi incorpora
tes
forbidden. or heterose (e.g., Mexican Am f-concept.
Differences indi-
of velopmenta cal develop
ment also
Native Americans sexxuuaal)l) exi erican or apparent l changes
Individual tribal beliefs influenc and ritua st through ide Cu ban Ameri in cul- eff ect on bo suc h as puber aff ect body im
e food practices. ls within nti can , ho Ho rm dy im ty an age .
BOX 36-6 PATIENT identity). one’s
e cultural fic ation with mo sexual on al changes age than on oth d aging have
TEACHING When cu gro up (e.g., Hi tra dit ion s, customs de vel opment du rin g adolesce er asp a mo re
Meditation Techniques tive, cultu
ura
rall pride
ltural
r identi
ty is centra spanic, , fat distribu of secondary sex nce influe ects of self-concep
Thatcher, and self-e l to sellff-ccon Latino, gender tion haave characte ter ris
isti
nce bodyy
im
ma age
ge.
t.
2013). ) An ind steem ten on cept and concept. a tremend ticcss and the . The
Objective dice, or en div d to be is posi- For ou changes in
provide other effective
options. Always respect nvvir
n iron
onmenta
i idual wh
ivi
o strong is a risk fac both male and fem s impact on an body
prayer rugs, or crosses the icons, medals, • The patient will verbaliz l stressors experiences discrimi (Rhea and tor for ma ale adolescent’
that a patient brings to e feelings of relaxation and
self-transcendence such as low nation, pre behaavi vioors
rs.. For exa n psycholo adolescents, negat
ny s self-
ensure that they are not a health setting and after meditation. -income ju- mple, an gical con ive body
accidentally lost, damag or high-c image an ad dit ion s image
Supporting spiritual rituals ed, or misplaced. rime d view he olescent gir tha t impact
is especially important ass ess rse lf as l ma a y he alt h
(Box 36-5). for older adults Teaching Strategies ment maa fat, which haave a distor
y reveal
• Give patient a brief descript that an ad signals an eating ted body
ion of information and a printed olescent dis
teachin
hingg guide ac tice engages in order. Y Your
Restorative and Continuing that describes how to meditat
e. rs in g Pr sel
sis for Nu
f-h armful
Care. For patients who are • Help patient identify a quiet room in cial Ba
Psychoso
ering from a long-term recov- e
Ex pe rie nc
illness or disability or who interruptions. the home that has minima
UNIT VI
terminal disease, spiritual suffer chronic or l
o
care becomes especially • Explain that peaceful music 708 e a patient wh
Kn ow le dg • Caring for
the nursing interventions important. Many of or the quiet whirring of body
applicable in health promo a fan blocks ed eration in
e of Alter
distractions. locks out
care apply to this level of tion and acute self-
ts of had an alt
health care as well. Suggestiv • Componen f-esteem,
role,
Behaviors
• Teach steps of meditation
Prayer. The act of prayer (i.e., sit in a comfortable position image, sel
gives an individual the with the back BOX 34
-5 concept
renew personal faith and opportunity to straight; breathe slowly; and
focus on a sound, prayer, or cept stress
ors or identity e of
pt • Self-con nication experienc
Self-Conce
belief in a higher being in • Encourage patient to meditat image). ion
way that is either highly a specific, focused self-evaluat ic commu • Personal f-concept
e for 10 to 20 minutes twice • Negative • Therapeut threat to sel
ritualized and formal or • Answer questions and reinforc a day.
and informal. Prayer is quite spontaneous e information as needed. of eye contact y dependent principles
an effective coping resour • Avoidance • Excessivel s or opinions s of
psychological symptoms ce for physical and to express view happening l indicator
(Oliver and Dutney, 2012). Evaluation • Slumped
posture • Hesitant t is • Nonverba
private or participate in Patients pray in appearance rest in wha distress
group prayer with family, • Have patient describe feelings • Unkempt • Lack of inte tors influen
cing
Some pray while listenin friends, or clergy. following meditation. atti tud e ral fac
logetic • Passive • Cu ltu
g to music. Be supportive • Overly apo in making dec
isions pt
the patient privacy if desired of prayer by giving
speech • Difficulty self-conce elopment
, learning if the patient wishes • Hesitant behaviors and dev
participate, and suggesting to have you ical or angry • Self-harm • Growth
prayer when you know • Overly crit
resource for the patient. that it is a coping or inappropria
te concepts ects of
• Frequent logical eff
Delgado (2015) has found insomnia, anxiety, and depres
pray for patients rather than that nurses tend to to relax (Cole et al.,
sion and increase coping
and the
he ability • Pharmaco
with patients; sharing the crying
has been offered gives patien fact that prayer 2012; Williams-Orlando,
2012). Medita medications
M EN T
ts comfort and support. involves sitting quietly in ditatio
tionn ns
nt Questio AS SE SS that suggest an
suitable for a patient, alterna If prayer is not a comfortable position with
Assessme
tives include listening to repeating a sound, phrase eyes closed
sed and
, or sacred word in rhythm ng
-6 Nursi
or reading a book, poetry calming music rs
for behavio
while disregarding intrusi with breath
, or inspirational texts selecte reathin
ingg
BOX 34 oncept
• Observe in the patient’s self-c
Meditation. Meditation d by the patient. ve thoughts. Individuals
regularly (twice a day who meditate
background
creates a relaxation respon m
alteration
for 10 or 20 minutes)
daily stress. Patients who se that reduces experience decrea the Proble s cultural
meditate often state that metabolism and heart rate,
easier breathing, and slower
creased
sed Nature of e yourself? the patient’ coping skills and
increased awareness of their they have an (Box 36-6). Chapter 33 brain ld you describ do you like? ut yourself. • As se ss s
n waves
wav • How wou appearance the patient’
a es
feel good abo
spirituality and of the presen addresses relaxation approa
a Supreme Being. Medita ce of God or ches. ects of your t make you out
• Assess
tion exercises give patien Supporting Grief Work. • Which asp gs you do tha you at carrying
ts relief from pain, Patients who experience ut the thin effective are resources gs and
who have suffered perma terminal illness
ness or • Tell me abo your primary roles. How nt’s feelin e,
nent loss of body functio
about ne the patie body imag
• Determi s about changes in
n because of a
• Tell me
se roles?
each of the perception
f? ste em , or role tie nt’s
d Duration about yoursel self-e of the pa
Onset an l differently , body image, the quality
think or fee cify identity
en did you start to h _____ (spe • Assess
• Wh struggled wit relationsh
ips
• How long
hav e you
or self-esteem
)?
abo ut yourself? tit ud es At
e, d
role perform
anc you felt goo
s curiosity in ient
remember a
time when St an da rd t’s • Display why a pat
• Can you of the patien considering in a particular
r ability to
take care • Support ma ke mig ht beh ave
Patient to
Effect on -con cep t affects you autonomy res s er
how your
self
choices and
exp ma nn en your
• Tell me integrity wh er
have on rela
tionship s?
values tha
t support • Display values diff
yourself. r self-esteem of your life? f-concept beliefs and nt’s; admit to
• What imp
act does you other areas , suicidal positive sel nd ard s pa tie
eem affect self-mutilation ellectual sta from the in your
s your self-est rself (specify • Apply int sistencies
• How doe hurting you and any incon t’s
con side red of relevance care to be your patien
• Have you for values or essary in
plausibility the patient risks if nec
gestures)? e to • Tak e g
acceptabl t’s right ping a trustin
Patient Teaching boxes emphasize important information ed for saf
e nursing
ess
care. In ass -concept
ponent of
self
ing self -
the
• Safeguard judiciously
to privacy
by
pat ien

of a
dev elo
relationshi
p with the
isions requir t focus on each com to information patient
to teach patients. clinical dec
concept and
self-esteem,
y image ,
firs
and rol e performa
nce). Assess
sug ges tive
ment needs
of an altered
ial self-
protecting
con fid ential nature
sel f-co nce pt assess
ment.

(identity, bod g for the range of beh

aviors
and potent g model for
5), actual tical thinkin
lud e loo kin (Bo x 34- ter ns. Ga thering FIG UR E 34-4 Cri e by ask ing them
inc m ing pat lth car
or self-estee 3), and cop sis of infor- ations of hea also an opportunity
self-concept Figure 34- ical synthe their expect is is
ssors (see uires the crit direct style. Assess ference. Th with a
concept stre assessment data req addition to normal life l make a dif rse working
e 34-4). In ncept entions wil mple, a nu diagnostic
comprehen
sive
ltip le sou rces (Figur dat a reg arding self-co ing how interv ien t’s goa ls. For exa to an upcoming e
mation fro
m mu
6), gat her much of the beh avi or and by pay to dis cuss the pat encing anxiety related
of the rela xation exercis
g (Box 34- nonverbal e of the o is experi ations se gives
questionin the patient’s s. Take not patient wh ut his expect The patient’s respon
h obs ervation of pat ien t’s conversation ir lives because ask s the patient abo tog ether. tud es regard-
thr oug t of the ple in the stu dy ctic ing and atti
the conten ut the peo nships and e been pra ut his beliefs ial need to modify
attention to ts talk abo tive relatio that they hav le information abo ent
which patien stressful and suppor al stages uab and the pot
manner in both development t and the nurse val of the interventions
es clues to wledge of the efficacy
this provid ass um es. Use kno tan t to the patien ing
patien t be im por le, ask a g approa ch. sid-
key roles the are likely to . For examp the nursin includes con
which areas person’s life important to him. essment also er, and inten-
to determine these aspects of the e nursing ass mb
ut what has bee
n
role per- pin g Be haviors. Th aviors; the nature, nu ernal resources.
inq uir e abo ut his life and a rela tin g to Co ing beh ext
patient abo provides dat previous cop internal and in the past pro-
70-year-old ’s conversation likely coping pat
terns. eration of the patient’s rs
ssors, and stressors; and with stresso ress all
The individ
ual
-esteem, stre sity of the t has dealt ts do not add n for
identity, self essing how a patien le of coping. Patien ter
formance, tan t factor in ass ion Kn owledge of or her sty fam ilia r coping pat
s. An im por
lth condit o his a ies to
tie nt’ s Eye her hea vid es insight int way, but they often use vious coping strateg
Pa or
Through the person’s viewpoint of ients the opportunity to g
his tell same pre
issues in the rs. Identify
nce pt is the pt. Giv e pat dit ion affe ctin enc oun tered stresso
self -co -conce or con new ly
uence on self perceive their illness to lead a
and its infl their ability
Nursing Assessment Questions boxes help you learn
y
of how the elves, and
their stories their image of thems
ty,
their identi
how to properly pose assessment questions when you The unique Critical Thinking Model clearly shows how
interview patients. critical thinking is to be applied during steps of the nursing
process to help you provide the best care for your patients.
x STUDENT PREFACE

425
y
obilit
Imm
28
PTER
CHA

esence
(e.g., pr ry
the legs ture, capilla
ion to ra of
an d circulat skin tempe ns for use
nt ’s skin n of skin, in dicatio
ing s tie io nt ra
INES Stock on of pa discolorat sess for co
conditi
G U IDEL g E lastic 3. Assess pulses, edem s or cuts).
a, As
RAL plyin l
of peda ence of le
sion
EDU d Ap ced by
PROC Devic
es an vices refill,
pres
ngs or
SCDs:
lesion
s eviden
28-7 on de stocki en skin ities as
ssion pressi elastic atitis or op extrem
BOX l C o mpre en tia l com nu rs e initial
ly
De rm af t n in lower
entia ions d sequ l (NAP). Th
e lower a. in gr
cent sk arterial circ .
ulat io
patient
’s
Sequ derat ngs an ne tient’s b. Re easure
Consi astic stocki stive person sses the pa ion. Instruct d
crease ol extremiti der.
es re to m
ation
ill
The sk n be delega
te
el
Deleg of applying d to nursing kings and
tic
assi
stoc T or
asse
impaire
d circ
ulat c. De
cyanot
ic, co
al th
ovider
care pr stockings, us .
or
e tape
measu
nt ’s lo wer ex
tremiti
es
Procedural Guidelines provide streamlined, step-by-step
ca of elas ptoms of DV d. tain he ng elastic ng size ene to patie
t of be develops in stocki
(SCDs) es the size
dete rm in
ities fo
r si gn s and sy
m
patie
lowing in leg or if
nt to get ou
discol
or at io n
at
4. Ob
5. W he n appl
legs to
yi
in e
determ giene. Also
proper provide hy
gi
ngs.
stocki rtable
instructions for performing the most basic skills.
extrem fore al in ities th hand hy elastic fo
: ves be plains of pa d activ rform t. Ds or bed to com
NAP to e SCD slee to avoi 6. Pe eded. uipmen plying SC
tient co
m
patient rters). are eq ap ad of
ov
• Rem nurse if pa nous as ne d prep on for ate he der
in st ru ct g ga ov e ve
sem bl e an
e an d re as n. El ev of pow
ify
• Not ities. st oc kings, le gs , wearin kings to im
pr
7. As n procedur supine posi
tio
al l amount itivity to
tic
extrem plying elas (e.g., crossi
ng stoc
8. Ex
plai in ply a sm t have sens
plying patient ngs, ap no
W he n ap us st asis d be fore ap Po sition tic stocki tient does
9. as
• e veno tting an ’s legs
.
level. plying
el
that pa
promot gs while si patient hen ap gs provided of stocking
s.
ate le assage tion: W le ion tten. ted
• Elev . Not m 10. Op rnstarch to ses applicat and fla indica
d Do s. ngs, or co unfold g position
return au tions an tic stocking on stocki Po wder
ea
cover; le
pr ec as es si sion er . (s ): as tic ing to
• Take wrinkles in
el
tic or compr co mpres eith
SC D Sleeve ve s from pl leg accord e up with
• Avoi
d Elas lcro ply D slee r patient’s ld lin
ional), justable Ve 11. Ap Remove SC e shou
rnstar
ch (opt
ed, ad a. eeve un eeve.
de of ankl
men
t
r or co attach supplies nge sl . Back ve (see
Equip sure, powde air hoses e b . Arra r lining of sl SC D sleeve ve. th e slee
en ee on
ea ), hygi me an
d on inne tient’s leg on lining of sl al opening
Tape m fflator with le sleeve(s y or na inner D slee
ve
insu birthda
e pa poplite fit of SC
SCD D disp
osab
e and c. Plac marking on with ee
ngs/SC ., nam ankle of knee Check ve (s
stocki ’s leg. g and slee
en tifi ers (e.g cy policy. lts ], si tio n back nd patient ’s le
id Po ou patient
s us in g two rding to agen ry te st resu d.
tra tion). se cu rely ar ee n
Step tify patient mber) acco ad: to Ill us ve betw
w’s tri [labora D slee gers
1. Iden al record nu ors in Vircho rders story rap SC two fin
g diso (i.e., hi e. W acing
medic r risk
fact clottin history by pl
(e.g., edical tion).
sess fo gulability tient m illustra
2. As rc oa in pa
a. Hy
pe ation) found
dehydr normalities sis) y) rd-
fever, sclero egnanc
all ab athero ity, pr ry acco s
nous w ic surgery, ty, obes bitis va ptom
b. Ve oped mobili bophle and sym ing
of orth is (e .g., im s of throm Si gn s ou nd
rr
ood st
as al sign mbus. and su perature
c. Bl : Clinic of the thro le veins m
ISION tion lpab arm. Te oms
AL DEC d loca include pa and w s and sympt m,
CLINIC e size an s ened, gn war
to th ro mbosi touch, redd esent. Si ; pain;
in g al th the pr ity the
su perfici tender to m ay not be ollen extrem gn (pain in e
of
that ar
e
a may
or
clude
sw
oman
s’ si reliabl
areas n and edem sis (DVT) in evation. H ed a
io bo el co nsider
elevat vein throm mperature longer 13).
te ) is no Werner, 20
of deep skin; and e foot
ic n of th e and
cyanot dorsiflexio 2015; Grinag
.,
calf on r (Ball et al
to
indica

.
sleeve
SCD ued
fit of Contin
Check
11e
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eal
oplit
the p
with
knee 742 UNIT VI Psychosocial Basis for Nursing Practice
ie nt’s
of pat
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Positi
11d
STEP g. NURSING CARE PLAN
in
open
Readiness for Enhanced Spiritual Well-Being
ASSESSMENT
Lisa Owens is a 61-year-old female who was diagnosed with stage IV breast cancer over 2 years ago. She has undergone numerous rounds of chemotherapy treat-
ment. Her husband, Richard, is 59 years old and a financial assistant at a local bank. The Owens have two children, both adults, with one daughter who is unmarried
and living only 2 miles away. The other child, a son, lives out of town. The son is married; he and his wife are about to have their first child. Lisa has numerous side
effects from her advancing disease and chemotherapy. She has ongoing hip pain from the cancer having spread to the bone. She also has reduced sensation in her
feet, chronic fatigue, and difficulty sleeping at night. Her husband provides most of her support at home, but this sometimes interferes with his ability to do the work
that he brings home. Lisa is coming to the outpatient chemotherapy infusion center to begin yet another course of chemotherapy. The nurse who has been seeing
Lisa in the center knows that the patient regularly attends church with her husband.

Assessment Activities Findings/Defining Characteristics*

Ask Lisa to describe what it is about her cancer that Lisa explains, “I have found it makes me appreciate what I have with my family. That being said,
frightens her most. I worry that I will not see my grandchild born, but I hope the chemotherapy will give me

Nursing Care Plans demonstrate how comprehensive a

Have Lisa tell you who she finds to be the greatest source of
support since she has been taking chemotherapy.
plan of care should be for a patient. Each plan helps you Ask Lisa if she feels satisfaction with her life.
some time and it will make me feel a bit better.”
Lisa has received support from her husband and daughter. She wants to be able to show them
her love, “I still want to be there for them.”
Lisa responds, “We always want more, don’t we? I have been blessed, but I think God gave
me this illness so I can show others what life means.”

understand the process of assessment, the association of *Defining characteristics are shown in bold type.

assessment findings with defining characteristics in the

NURSING DIAGNOSIS: Readiness for Enhanced Spiritual Well-Being

PLANNING

formation of nursing diagnoses, the identification of goals Goals Expected Outcomes (NOC)†
Hope

and outcomes, the selection of nursing interventions, and Lisa will express her will to live with family members. Lisa participates in worship with her family and shares spiritual readings.
Lisa connects with members of her church.
Lisa interacts with family members and discusses their future.
the process for evaluating care. Lisa will describe a feeling of peacefulness to her family.
Spiritual Health
Lisa engages in regular prayer and meditation.
Lisa will express a personal sense of spiritual well-being. Lisa expresses her feelings through writing.
†
Outcome classification labels from Moorhead S et al: Nursing outcomes classification (NOC), ed 5, St Louis, 2013, Mosby.

INTERVENTIONS (NIC)‡ RATIONALE

Spiritual Growth Facilitation
Plan discussions with Lisa during treatment and listen, allowing her to Listening provides support or comfort in spiritual care (Delgado, 2015). Family
Nursing Interventions Classification (NIC) and sort out concerns she might have about her future. Include Lisa’s
husband if she desires.
caregivers engage in “meaning making” activities by expressing important values
such as hope, dignity, and togetherness (Delgado-Guay, 2014).

Nursing Outcomes Classification (NOC) terminologies Offer to pray with Lisa as she describes what she hopes for.
Introduce Lisa to journaling. Encourage her to begin by writing what is
are used in the care plans to build your knowledge of meaningful to her about her illness and family
nursing concepts. Spiritual Support
Discuss with Lisa the likely times that her chemotherapy will affect her
most and how she can schedule involvement in church activities
One study found that cancer patients commonly used prayer and meditation to
reduce their side effects (Huebner et al., 2014)
Use of journaling helps individuals facing a crisis deal with the unknown; find
meaning and spiritual connection; and physically, emotionally, and spiritually heal
(Harvey et al., 2013; Sealy, 2013).
Chemotherapy can cause severe fatigue. Faith communities such as a church play an
important role in fostering belief systems of compassion (Delgado-Guay, 2014).

Rationales for each of the interventions in the care

around those times.
Teach Lisa methods of relaxation, meditation, and guided imagery.
plans demonstrate the evidence to support nursing care
Relaxation methods help promote quality of life and enhance serenity and dignity.
Relaxation responses have been associated with improved physiological (blood
pressure, exercise capacity, and cardiac symptoms) and psychological (depression
and anxiety) outcomes (Horowitz, 2010; Sheeba et al., 2013).

approaches. ‡
Intervention classification labels from Bulechek GM et al: Nursing interventions classification (NIC), ed 6, St Louis, 2013, Mosby.

EVALUATION
Nursing Actions
Evaluation section explains how to evaluate and Ask Lisa to describe in what way
relaxation exercises have helped her.
Patient Response/Finding Achievement of Outcome
Lisa reported using relaxation daily after being at clinic. She states,
“I feel calm. It allows me to connect with God, and know I have
Lisa’s story reflects spiritual well-being
and peacefulness. She needs to share

determine whether patient outcomes have been achieved. Have Lisa review her discussions with
my loving family to help me.”
Lisa reports, “We have been talking more. My family knows that I
with family.
Lisa is connecting with family and church
family and/or church members. see each day as a blessing and that my hope is to see my son’s members. She is able to express a
baby. My church really keeps me connected.” sense of hope.
 STUDENT PREFACE xi

CHAPTER 34 Self-Concept 711

individual and key critical thinking elements (see the Nursing Care Goals and Outcomes. Develop an individualized plan of care for
Plan). Professional standards are especially important to consider each nursing diagnosis. Work collaboratively with the patient to set
when developing a plan of care. These standards often establish ethical realistic expectations for care. Make sure that goals are individualized
or evidence-based practice guidelines for selecting effective nursing and realistic with measurable outcomes. In establishing goals consult

Concept Maps help you see the connections between

interventions.
Another method to help plan care is a concept map. An example of
an illustrative concept map (Figure 34-6) shows the relationship of a
your patient’s medical problems and your plan of care. primary health problem (postoperative bilateral radical mastectomy)
and four nursing diagnoses and several interventions. The concept
map shows how the nursing diagnoses are interrelated. It also helps to
show the interrelationships among nursing interventions. A single
nursing intervention can be effective for more than one diagnosis.
with the patient about whether they are achievable. Consultation with
significant others, mental health clinicians, and community resources
results in a more comprehensive and workable plan. When you set
goals, consider the data necessary to demonstrate that the patient’s
problem would change if the nursing diagnosis were managed. The
outcome criteria should reflect these changes. For example, a patient
is diagnosed with Situational Low Self-Esteem related to a recent job
layoff. Establish a goal: “Patient’s self-esteem and self-concept will

C ONCEPT M AP

Nursing Skills are presented in a clear, two-column Nursing diagnosis: Disturbed body image Nursing diagnosis: Acute pain
format that includes Steps and Rationales to help you learn • Does not touch her chest
• Unable to look in mirror
• Rates postoperative pain as a 9 on a scale of
0 to 10
how and why a skill is performed. Each skill begins with • Avoids new social interactions
• Fears husband’s response to loss of breasts
• States “no relief from pain” with PCA
• Has poor sleeping patterns
• Has a lack of appetite
a Safety Guidelines section that will help you focus on • Has decreased nutritional intake

safe and effective skill performance. Int

In erventions
Interventions Interventions
• Assist patient to develop a realistic perception of • Ask k patient to describe past methods used to
432 her body
dy image control pain
UN • Tell patient that
at her feelings are similar to feelings • Explore the need for opioid and nonnarcotic
IT Vof other people in the same situation analgesics
SAF • Show Foacceptance
un of mastectomy
my when providing care • Discuss patient’s fears of undertreated
r pain
ETY datio and addiction
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est e rpora a te cl ti RSIN ice
Delegation Considerations guide you in delegating tasks form al ro
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DEL 28-1 alth b feelings
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8. Assess condition of patient’s skin (see Chapter 31). Provides baseline to determine effects of positioning. nt; m eque ways
tion:
D e Tract nt is un ifficulty u sc n t re to im d
9. Assess ability and motivation of patient and family caregivers to participate in Determines ability of patient and caregiversf. to help with positioning. crea ion o a in le p prove
Leve sed
fr m r art ble to pro moving tone ch ositionin positi
moving and positioning patient in bed in anticipation of discharge to home. l of co om C otion hritic tect and ange g. on
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a. A phys a n erlyi in de is et al. part,
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IMPLEMENTATION t’ s he posi ess a rt r re b il se fr a
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1. Assist Patient in Moving Up in Bed Determines degree of risk in6.repositioning patient and technique weig required to safely les n not s or ssure nsati e ult
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(2) Partially able to assist; patient can assist with nurse using positioning ssess s, cu ca re Limit ines am disease ore slow atient’s on, a elp of
cues or aids (e.g., drawsheet or friction-reducing device). for p and tubin lties; cert use of p position Devi
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CLINICAL DECISION: Before lowering head of bed to flatten bed, account for all tubing, drains, and equip- es, in al co io ethe r safe rovid ave . ISN8 ines
cisio nditio n (e.g., r any equ ts re p a ce rt a e d b yp
h e a d , 2 0
ment to prevent dislodgement or tipping if caught in mattress or bedframe as bed is lowered. ns, a ns; p sp qu tie in of 15).
nd e
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b. Assist patient moving up in bed, using a drawsheet (two or three This is not a one-person task. Helping a patient move up in bed without help (e.g., - t in a nd li if on ch
tr n ina Fairchil fts, whe ferent w
nurses). other co-workers or without the aid of an assistive device (i.e., friction-reducing action). ppro d elcha eigh ange
priate , 2013). irs, t restri .
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(1) Place patient supine with head of bed flat. A nurse stands on each side Enables nurse to assess body alignment. Reduces pull of gravity on patient’s upper positi sitioning injury
. bath
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of bed. body. d u re an
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(2) Remove pillow from under head and shoulders and place it at head of Prevents striking patient’s head against head of bed. ects
patie
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abilit
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(3) Turn patient side to side to place drawsheet under patient, extending Supports patient’s body weight and reduces friction during movement. inde
pend
from shoulders to thighs. ently
chan
(4) Return patient to supine position. Even distribution of patient’s weight makes lifting and positioning easier. ge
(5) Fanfold drawsheet on both sides, with each nurse grasping firmly near Provides strong handles to grip drawsheet without slipping.
patient.

CLINICAL DECISION: Protect patient’s heels from shearing force by having a third nurse lift heels while
moving patient up in bed.

(6) Nurses place their feet apart with forward-backward stance. Flex knees Facing direction of movement ensures proper balance. Shifting weight reduces
Clinical Decisions alert you to important information
and hips. On the count of three, shift weight from front to back leg
and move patient and drawsheet to desired position in bed (see
force needed to move load. Flexing knees lowers center of gravity and uses
thigh muscles instead of back muscles.
within a skill to consider to ensure safe and effective
illustration).
patient care.
Clear, close-up photos and illustrations show you how to
perform important skill procedures.

A B
STEP 1b(6) A and B, Moving immobile patient up in bed with drawsheet.
xii STUDENT PREFACE

659

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KEY POINTS 3. You convince Ms. Cavallo to eat a balanced diet of three meals and
dos m e
O RD a ti on that an on of fa mily ic a tion on wit safely ter m two snacks high in protein. Describe the decision-making process
RE
C
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a valu nt a of m e ble a • Use findings from evidence-based nursing research about safe you use to ensure that Ms. Cavallo continues to recognize the
C hart the re port e . f p atie p e cts take m If una ble to
• ecord nd re ider) o S a s s. na patient handling to prevent injuries to nurses and patients when importance of a balanced diet. Include essential assessment data
a v tion ION t all er to tion is u
• R ecord re pro valua AT bou wheth medica t still moving and transferring. that you need to ensure that she continues to have an intake of
• R alth c t your
a e ER rs a d en
he men SID re give cts, an inister d pati • Coordination and regulation of muscle groups depend on muscle proper foods.
N a e n
ocu CO ily c ide eff elf-adm fail a tone; activity of antagonistic, synergistic, and antigravity muscles;
• D RE fam s s ns
CA and ated afely entio and neural input to muscles. Answers to Clinical Application Questions can be found on the
ME ents anticip y to s interv Evolve website.
HO pati it • Body alignment is the condition of joints, tendons, ligaments, and
s tr uct ations, s abil tion. If
t’ a muscles in various body positions.
• In medic patien ministr
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REVIEW QUESTIONS
valu s
• E sist in gravity falls within the base of support, and a vertical line falls from
as the center of gravity through the base of support. Are You Ready to Test Your Nursing Knowledge?
• Developmental stages influence body alignment and mobility; the 1. An older adult has limited mobility as a result of a total knee
greatest impact of physiological changes on the musculoskeletal replacement. During assessment you note that the patient has
system is observed in children and older adults. difficulty breathing while lying flat. Which of the following assess-
• The risk of disabilities related to immobilization depends on the ment data support a possible pulmonary problem related to
extent and duration of immobilization and the patient’s overall impaired mobility? (Select all that apply.)
level of health. 1. B/P = 128/84
• Immobility presents hazards in the physiological, psychological, 2. Respirations 26/min on room air
and developmental dimensions. 3. HR 114
• The nursing process and critical thinking assist you in providing 4. Crackles over lower lobes heard on auscultation
care for patients who are experiencing or are at risk for the adverse 5. Pain reported as 3 on scale of 0 to 10 after medication
effects of impaired body alignment and immobility. 2. A patient has been on bed rest for over 4 days. On assessment,
• Patients with impaired body alignment require nursing care to the nurse identifies the following as a sign associated with
maintain correct positioning such as the supported Fowler’s, immobility:
supine, prone, side-lying, and Sims’ positions. 1. Decreased peristalsis
• Patient movement algorithms serve as assessment tools and guide 2. Decreased heart rate
safe patient handling and movement. 3. Increased blood pressure
• Appropriate friction-reducing assistive devices and mechanical lifts 4. Increased urinary output
need to be used for patient transfers when applicable. 3. The nurse puts elastic stockings on a patient following
• No-lift policies benefit all members of the health care system: major abdominal surgery. The nurse teaches the patient that
patients, nurses, and administration. the stockings are used after a surgical procedure to

Home Care Considerations explain how to adapt skills __________________________.

4. A nurse is teaching a community group about ways to minimize
CLINICAL APPLICATION QUESTIONS the risk of developing osteoporosis. Which of the following state-
for the home setting. Preparing for Clinical Practice
ments reflect understanding of what was taught? (Select all that
apply.)
Ms. Cavallo, 97 years of age, has been a resident at the rehabilitation 1. “I usually go swimming with my family at the YMCA 3 times
unit for 6 weeks. She has been receiving rehabilitation therapy follow- a week.”
ing the repair of her fractured left hip. The nursing assistive personnel 2. “I need to ask my doctor if I should have a bone mineral
(NAP) tells you that Ms. Cavallo has not been finishing her meals over density check this year.”
the past 2 days because of poor appetite. As you enter her room with 3. “If I don’t drink milk at dinner, I’ll eat broccoli or cabbage to
a food tray today, she states, “Go away and take that tray of food with get the calcium that I need in my diet.”
you. I’m tired of all of this, and I just want to stay in bed today.” You 4. “I’ll check the label of my multivitamin. If it has calcium, I can
explore why she feels this way. You discover that she does not like the save money by not taking another pill.”
foods that are being prepared for her and she does not feel strong 5. “My lactose intolerance should not be a concern when consid-
enough to use her walker. She states, “I’m afraid that I’m going to fall ering my calcium intake.”
because I don’t feel strong enough to get out of bed and use my walker.” 5. A nurse is caring for an older adult who has had a fractured hip
1. On the basis of these data, you develop a nursing diagnosis repaired. In the first few postoperative days, which of the following
of Deficient Knowledge (Imbalanced Nutrition: Less Than Body nursing measures will best facilitate the resumption of activities
Requirements) related to lack of information. Identify one goal, of daily living for this patient?
two expected outcomes, and three related nursing interventions 1. Encouraging use of an overhead trapeze for positioning and
with rationales that will help her meet the identified goal and transfer
outcomes. 2. Frequent family visits
2. You finish teaching Ms. Cavallo about the importance of a bal- 3. Assisting the patient to a wheelchair once per day
anced diet and how it will help her regain strength to ambulate. 4. Ensuring that there is an order for physical therapy
As you are doing her morning assessment, you notice that she has 6. An older-adult patient has been bedridden for 2 weeks. Which of
a reddened area on her coccyx. the following complaints by the patient indicates to the nurse that
a. Which risk factors contribute to this finding? he or she is developing a complication of immobility?
b. In addition to a balanced diet, which other nursing interven- 1. Loss of appetite
tions would be good to include in her plan of care? 2. Gum soreness
 P R E FAC E TO T H E I N S T RU C TO R
The nursing profession is always responding to dynamic change
and continual challenges. Today nurses need a broad knowledge
base from which to provide care. More important, nurses require the
ability to know how to apply best evidence in practice to ensure the
best outcomes for their patients. The role of the nurse includes assum-
ing the lead in preserving nursing practice and demonstrating its con-
tribution to the health care of our nation. Nurses of tomorrow,
therefore, need to become critical thinkers, patient advocates, clinical
decision makers, and patient educators within a broad spectrum of
care services.
The ninth edition of Fundamentals of Nursing was revised to
prepare today’s students for the challenges of tomorrow. This textbook
is designed for beginning students in all types of professional nursing
programs. The comprehensive coverage provides fundamental nursing
concepts, skills, and techniques of nursing practice and a firm founda-
tion for more advanced areas of study.
Fundamentals of Nursing provides a contemporary approach to
nursing practice, discussing the entire scope of primary, acute, and
restorative care. This new edition continues to address a number of
key current practice issues, including an emphasis on patient-centered
care and evidence-based practice. Evidence-based practice is one of the
most important initiatives in health care today. The increased focus on
applying current evidence in skills and patient care plans helps stu-
dents understand how the latest research findings should guide their
clinical decision making.
KEY FEATURES
We have carefully developed this ninth edition with the student in
mind. We have designed this text to welcome the new student to
nursing, communicate our own love for the profession, and promote
learning and understanding. Key features of the text include the
following:
• Students will appreciate the clear, engaging writing style. The nar-
rative actually addresses the reader, making this textbook more of
an active instructional tool than a passive reference. Students will
find that even complex technical and theoretical concepts are pre-
sented in a language that is easy to understand.
• Comprehensive coverage and readability of all fundamental
nursing content.
• The attractive, functional design will appeal to today’s visual
learner. The clear, readable type and bold headings make the
content easy to read and follow. Each special element is consis-
tently color-keyed so students can readily identify important
information.
• Hundreds of large, clear, full-color photographs and drawings
reinforce and clarify key concepts and techniques.
• The nursing process format provides a consistent organizational
framework for clinical chapters.
• Learning aids help students identify, review, and apply important
content in each chapter and include Objectives, Key Terms, Key
Points, Clinical Application Questions, and Review Questions.
• Evolve Resources lists at the beginning of every chapter detail the
electronic resources available for the student.
• Health promotion and acute and continuing care are covered to
address today’s practice in various settings.
• A health promotion/wellness thread is used consistently through-
out the text.
• Cultural awareness, care of the older adult, and patient teaching
are stressed throughout chapter narratives and are highlighted in
special boxes.
• Procedural Guidelines boxes provide more streamlined, step-by-
step instructions for performing very basic skills.
• Concept Maps in each clinical chapter show you the asso-
ciation between multiple nursing diagnoses for a patient with a
selected medical diagnosis and the relationship between nursing
interventions.
• Nursing Care Plans guide students on how to conduct an assess-
ment and analyze the defining characteristics that indicate nursing
diagnoses. The plans include NIC and NOC classifications to famil-
iarize students with this important nomenclature. The evaluation
sections of the plans show students how to evaluate and then deter-
mine the outcomes of care.
• A critical thinking model provides a framework for all clinical
chapters and show how elements of critical thinking, including
knowledge, critical thinking attitudes, intellectual and professional
standards, and experience are integrated throughout the nursing
process for making clinical decisions.
• More than 50 nursing skills are presented in a clear, two-column
format with steps and supporting rationales that are often sup-
ported with current, evidence-based research.
• Delegation Considerations guide when it is appropriate to dele-
gate tasks to assistive personnel.
• Unexpected Outcomes and Related Interventions are highlighted
within nursing skills to help students anticipate and appropriately
respond to possible problems faced while performing skills.
• Video Icons indicate video clips associated with specific skills that
are available online in the Evolve Student Resources.
• Printed endpapers on the inside back cover help students locate
specific assets in the book, including Skills, Procedural Guidelines,
Nursing Care Plans, and Concept Maps.
NEW TO THIS EDITION
• Information related to the Quality and Safety Education for
Nurses (QSEN) initiative is highlighted by headings that coordinate
with the key competencies. Building Competency scenarios in each
chapter incorporate one of the six key competencies in QSEN.
Answers to these activities can be found online in the Evolve
Student Resources.
• The latest NANDA 2015-2017 diagnoses are included for up-to-
date content.
• A new skill covers Fall Prevention in Health Care Settings.
• Review Questions have been updated in each chapter, with a
minimum of four alternate-item type questions. Answers are pro-
vided with questions and rationales on Evolve.
• Evidence-Based Practice boxes in each chapter have been updated
to reflect current research topics and trends.
• Both Healthy People 2020 and The Joint Commission’s 2016
National Patient Safety Goals are covered in this new edition,
promoting the importance of current research.
• Chapter 28: Immobility and Chapter 39: Activity and Exercise
have been completely reorganized to reduce redundancy, improve
clarity, and increase the clinical focus of both chapters.
• Chapter 9: Cultural Awareness has been completely rewritten and
revised to better address this topic for fundamentals students.
xiii
xiv PREFACE TO THE INSTRUCTOR
LEARNING SUPPLEMENTS FOR STUDENTS
• The Evolve Student Resources are available online at http://
evolve.elsevier.com/Potter/fundamentals/ and include the follow-
ing valuable learning aids organized by chapter:
• Chapter Review Questions from the book in an interactive
format! Includes hundreds of questions to prepare for
examinations.
• Answers and rationales to Chapter Review Questions
• Answers and rationales to Clinical Application Questions
• Answers and rationales to Building Competency scenario
questions
• Video clips to highlight common skills and procedural
guidelines
• Concept Map Creator (included in each clinical chapter)
• Conceptual Care Map (included in each clinical chapter)
• Case Study with Questions
• Audio Glossary
• Fluids & Electrolytes Tutorial
• Calculation Tutorial
• Printable versions of Chapter Key Points
• Interactive Skills Performance Checklists (included for each skill
in the text)
• A thorough Study Guide by Geralyn Ochs provides an ideal supple-
ment to help students understand and apply the content of the text.
Each chapter includes multiple sections:
• Preliminary Reading includes a chapter assignment from
the text.
• Comprehensive Understanding provides a variety of activities
to reinforce the topics and main ideas from the text.
• Review Questions are NCLEX®-style multiple-choice questions
that require students to provide rationales for their answers.
Answers and rationales are provided in the answer key.
• Clinical chapters include an Application of Critical Thinking
Synthesis Model that expands the case study from the chapter’s
Care Plan and asks students to develop a step in the synthesis
model based on the nurse and patient in the scenario. This helps
students learn to apply both content learned and the critical
thinking synthesis model.
• The handy Clinical Companion: Just the Facts complements,
rather than abbreviates, the textbook. Content is presented in a
tabular, list, and outline format that equips your students with a
concise, portable guide to all the facts and figures they’ll need to
know in their early clinical experiences.
• Virtual Clinical Excursions is an exciting workbook and CD-ROM
experience that brings learning to life in a virtual hospital setting.
The workbook guides students as they care for patients, providing
ongoing challenges and learning opportunities. Each lesson in
Virtual Clinical Excursions complements the textbook content and
provides an environment for students to practice what they are
learning. This CD/workbook is available separately or packaged at
a special price with the textbook.
TEACHING SUPPLEMENTS FOR INSTRUCTORS
The Evolve Instructor Resources (available online at http://
evolve.elsevier.com/Potter/fundamentals) are a comprehensive collec-
tion of the most important tools instructors need, including the
following:
• TEACH for Nurses ties together every chapter resource you need
for the most effective class presentations, with sections dedicated
to objectives, teaching focus, nursing curriculum standards (includ-
ing QSEN, BSN Essentials, and Concepts), instructor chapter
resources, student chapter resources, answers to chapter questions,
and an in-class case study discussion. Teaching Strategies include
relations between the textbook content and discussion items.
Examples of student activities, online activities, new health
promotion-focused activities, and large group activities are pro-
vided for more “hands-on” learning.
• The Test Bank contains 1500 questions with text page references
and answers coded for NCLEX Client Needs category, nursing
process, and cognitive level. Each question was involved in an
instructor piloting process to ensure the best possible exam for
students. The ExamView software allows instructors to create new
tests; edit, add, and delete test questions; sort questions by NCLEX
category, cognitive level, nursing process step, and question type;
and administer/grade online tests.
• Completely revised PowerPoint Presentations include more
than 1500 slides for use in lectures. Art is included within the slides,
and progressive case studies include discussion questions and
answers.
• The Image Collection contains more than 1150 illustrations from
the text for use in lectures.
• Simulation Learning System is an online toolkit that helps instruc-
tors and facilitators effectively incorporate medium- to high-
fidelity simulation into their nursing curriculum. Detailed patient
scenarios promote and enhance the clinical decision-making skills
of students at all levels. The system provides detailed instructions
for preparation and implementation of the simulation experience,
debriefing questions that encourage critical thinking, and learn-
ing resources to reinforce student comprehension. Each scenario
in Simulation Learning System complements the textbook content
and helps bridge the gap between lectures and clinicals. This system
provides the perfect environment for students to practice what
they are learning in the text for a true-to-life, hands-on learning
experience.
MULTIMEDIA SUPPLEMENTS
FOR INSTRUCTORS AND STUDENTS
• Nursing Skills Online 3.0 contains 18 modules rich with anima-
tions, videos, interactive activities, and exercises to help students
prepare for their clinical lab experience. The instructionally
designed lessons focus on topics that are difficult to master and
pose a high risk to the patient if done incorrectly. Lesson quizzes
allow students to check their learning curve and review as needed,
and the module exams feed out to an instructor grade book.
Modules cover Airway Management, Blood Therapy, Bowel
Elimination/Ostomy Care, Chest Tubes, Enteral Nutrition, Infec­
tion Control, Injections, IV Fluid Administration, IV Fluid Therapy
Management, IV Medication Administration, Nonparenteral
Medication Administration, Safe Medication Administration,
Safety, Specimen Collection, Urinary Catheterization, Vascular
Access, Vital Signs, and Wound Care. Available alone or packaged
with the text.
• Mosby’s Nursing Video Skills: Basic, Intermediate, Advanced, 4th
edition provides 126 skills with overview information covering skill
purpose, safety, and delegation guides; equipment lists; preparation
procedures; procedure videos with printable step-by-step guide-
lines; appropriate follow-up care; documentation guidelines; and
interactive review questions. Available online, as a student DVD set,
or as a networkable DVD set for the institution.
 AC K N OW L E D G M E N T S
The ninth edition of Fundamentals of Nursing is one that we believe
continues to prepare the student nurse to be able to practice in the
challenging health care environment. Collaboration on this project
allows us to be creative, visionary, and thoughtful as to students’ learn-
ing needs. Each edition is a new adventure for all of us on the author
team as we try to create the very best textbook for beginning nurses.
Each of us wishes to acknowledge the professionalism, support, and
commitment to detail from the following individuals:
• The editorial and production professionals at Mosby/Elsevier,
including:
• Tamara Myers, Executive Content Strategist, for her vision,
organization, professionalism, energy, and support in assisting
us to develop a text that offers a state-of-the-art approach to
the design, organization, and presentation of Fundamentals of
Nursing. Her skill is in motivating and supporting a writing
team so it can be creative and innovative while retaining the
characteristics of a high-quality textbook.
• Jean Sims Fornango, Content Development Manager for
Fundamen­tals of Nursing, for her professionalism and commit-
ment to excellence. Her editorial and publishing skills provide
a vision for organizing and developing the manuscript while
ensuring that all pieces of the book and ancillary materials are
creative, stimulating, and state-of-the-art. She, like the rest of
the team, goes the extra mile sharing her energy and spirit.
• Tina Kaemmerer as our Senior Content Development Specialist
for Fundamentals of Nursing. She is dedicated to keeping the
writing team organized and focused, performing considerable
behind-the-scenes work for ensuring accuracy and consistency
in how we present content within the textbook. She has limitless
energy and is always willing to go the extra mile.
• Jodi Willard, Senior Project Manager, consistently performs
miracles. She is an amazing and accomplished production editor
who applies patience, humor, and attention to detail. It is an
honor to work with Jodi because of her professionalism and
ability to coordinate the multiple aspects of completing a well-
designed finished product.
• StoryTrack, St. Louis, Missouri, for their excellent photography.
• Maryville University, who allowed us to use the new Myrtle E. and
Earl E. Walker Hall for the new photographs.
• To our contributors and clinician and educator reviewers, who
share their expertise and knowledge about nursing practice and the
trends within health care today, helping us to create informative,
accurate, and current information. Their contributions allow us
to develop a text that embodies high standards for professional
nursing practice through the printed word.
• And special recognition to our professional colleagues at Barnes-
Jewish Hospital, Southern Illinois University—Edwardsville, Saint
Francis Medical Center College of Nursing, and the University of
Evansville.
We believe that Fundamentals of Nursing, now in its ninth edition, is a
textbook that informs and helps to shape the standards for excellence
in nursing practice. Nursing excellence belongs to all of us, and we are
happy to have the opportunity to continue the work we love.
Patricia A. Potter
Anne Griffin Perry
Patricia A. Stockert
Amy M. Hall
xv
CONTENTS
Any updates to this textbook can be found in the Content Updates Illness, 73
folder on Evolve at http://evolve.elsevier.com/Potter/fundamentals/. Caring for Yourself, 75
7 Caring in Nursing Practice, 79
Anne Griffin Perry, RN, MSN, EdD, FAAN
UNIT I Nursing and the Health Care Environment Theoretical Views on Caring, 80
Patients’ Perceptions of Caring, 83
1 Nursing Today, 1 Ethic of Care, 83
Anne Griffin Perry, RN, MSN, EdD, FAAN Caring in Nursing Practice, 84
Nursing as a Profession, 1 The Challenge of Caring, 87
Historical Influences, 5 8 Caring for the Cancer Survivor, 90
Contemporary Influences, 6 Kay E. Gaehle, PhD, MSN, BSN
Trends in Nursing, 7 The Effects of Cancer on Quality of Life, 90
Professional Registered Nurse Education, 9 Cancer and Families, 94
Nursing Practice, 10 Implications for Nursing, 94
Professional Nursing Organizations, 10 Components of Survivorship Care, 96
2 The Health Care Delivery System, 14 9 Cultural Awareness, 101
Patricia A. Stockert, RN, BSN, MS, PhD Brenda Battle, RN, BSN, MBA
Health Care Regulation and Reform, 15 Jelena Todic, MSW, LCSW
Emphasis on Population Wellness, 16 Health Disparities, 101
Health Care Settings and Services, 17 Culture, 102
Issues and Changes in Health Care Delivery, 22 Cultural Competency, 103
Quality and Performance Improvement, 26 Core Measures, 111
The Future of Health Care, 27 10 Caring for Families, 117
3 Community-Based Nursing Practice, 31 Anne Griffin Perry, RN, MSN, EdD, FAAN
Anne Griffin Perry, RN, MSN, EdD, FAAN The Family, 117
Community-Based Health Care, 31 Family Forms and Current Trends, 118
Community Health Nursing, 33 Impact of Illness and Injury, 120
Community-Based Nursing, 33 Approaches to Family Nursing: An Overview, 120
Community Assessment, 37 Family Nursing, 122
Changing Patients’ Health, 37 Nursing Process for the Family, 123
4 Theoretical Foundations of Nursing Practice, 41 Implementing Family-Centered Care, 126
Beverly J. Reynolds, RN, EdD, CNE 11 Developmental Theories, 132
Theory, 41 Tara Hulsey, PhD, RN, CNE, FAAN
Shared Theories, 45 Developmental Theories, 132
Select Nursing Theories, 45 12 Conception Through Adolescence, 141
Link Between Theory and Knowledge Development in Jerrilee LaMar, PhD, RN, CNE
Nursing, 48 Stages of Growth and Development, 141
5 Evidence-Based Practice, 52 Selecting a Developmental Framework for
Amy M. Hall, RN, BSN, MS, PhD, CNE Nursing, 141
The Need for Evidence-Based Practice, 52 Intrauterine Life, 141
Nursing Research, 57 Transition from Intrauterine to Extrauterine Life, 142
Research Process, 60 Newborn, 142
The Relationship Between EBP, Research, and Quality Infant, 145
Improvement, 61 Toddler, 147
Preschoolers, 149
UNIT II Caring Throughout the Life Span School-Age Children and Adolescents, 150
School-Age Children, 151
6 Health and Wellness, 65 Adolescents, 153
Patricia A. Stockert, RN, BSN, MS, PhD 13 Young and Middle Adults, 159
Healthy People Documents, 65 Patsy L. Ruchala, DNSc, RN
Definition of Health, 66 Young Adults, 159
Models of Health and Illness, 66 Middle Adults, 166
Variables Influencing Health and Health Beliefs and 14 Older Adults, 173
Practices, 69 Gayle L. Kruse, RN, ACHPN, GCNS-BC
Health Promotion, Wellness, and Illness Prevention, 70 Variability Among Older Adults, 173
Risk Factors, 72 Myths and Stereotypes, 174
Risk-Factor Modification and Changing Health Nurses’ Attitudes Toward Older Adults, 174
Behaviors, 72 Developmental Tasks for Older Adults, 174

xvi

Community-Based and Institutional Health Care
Services, 175
Assessing the Needs of Older Adults, 175
Addressing the Health Concerns of Older Adults, 183
Older Adults and the Acute Care Setting, 190
Older Adults and Restorative Care, 190
UNIT III Critical Thinking in Nursing Practice
15 Critical Thinking in Nursing Practice, 195
Patricia A. Potter, RN, MSN, PhD, FAAN
Clinical Judgment in Nursing Practice, 195
Critical Thinking Defined, 196
Levels of Critical Thinking in Nursing, 197
Critical Thinking Competencies, 198
A Critical Thinking Model for Clinical Decision
Making, 201
Critical Thinking Synthesis, 205
Developing Critical Thinking Skills, 205
Managing Stress, 206
16 Nursing Assessment, 209
Patricia A. Potter, RN, MSN, PhD, FAAN
A Critical Thinking Approach to Assessment, 210
The Patient-Centered Interview, 215
Nursing Health History, 217
17 Nursing Diagnosis, 225
Patricia A. Potter, RN, MSN, PhD, FAAN
History of Nursing Diagnosis, 226
Types of Nursing Diagnoses, 227
Critical Thinking and the Nursing Diagnostic
Process, 230
Concept Mapping Nursing Diagnoses, 234
Sources of Diagnostic Errors, 234
Documentation and Informatics, 236
Nursing Diagnoses: Application to Care Planning, 237
18 Planning Nursing Care, 240
Patricia A. Potter, RN, MSN, PhD, FAAN
Establishing Priorities, 241
Critical Thinking in Setting Goals and Expected
Outcomes, 242
Critical Thinking in Planning Nursing Care, 245
Systems for Planning Nursing Care, 248
Consulting with Other Health Care
Professionals, 252
19 Implementing Nursing Care, 257
Patricia A. Potter, RN, MSN, PhD, FAAN
Standard Nursing Interventions, 258
Critical Thinking in Implementation, 259
Implementation Process, 261
Direct Care, 264
Indirect Care, 266
Achieving Patient Goals, 266
20 Evaluation, 270
Patricia A. Potter, RN, MSN, PhD, FAAN
Critical Thinking in Evaluation, 270
Standards for Evaluation, 276
21 Managing Patient Care, 279
Patricia A. Stockert, RN, BSN, MS, PhD
Building a Nursing Team, 279
Leadership Skills for Nursing Students, 284
Contents xvii
UNIT IV Professional Standards
in Nursing Practice
22 Ethics and Values, 292
Margaret Ecker, RN, MS
Basic Terms in Health Ethics, 292
Professional Nursing Code of Ethics, 293
Values, 294
Ethics and Philosophy, 294
Nursing Point of View, 295
Issues in Health Care Ethics, 297
23 Legal Implications in Nursing Practice, 302
Alice E. Dupler, JD, APRN-ANP, Esq.
Legal Limits of Nursing, 302
Federal Statutory Issues in Nursing Practice, 303
State Statutory Issues in Nursing Practice, 307
Civil and Common Law Issues in Nursing Practice, 308
Risk Management and Quality Assurance, 312
24 Communication, 316
Cheryl A. Crowe, RN, MS
Communication and Nursing Practice, 316
Elements of the Communication Process, 319
Forms of Communication, 320
Professional Nursing Relationships, 321
Elements of Professional Communication, 324
Nursing Process, 325
25 Patient Education, 336
Katherine N. Ayzengart, MSN, RN
Standards for Patient Education, 336
Purposes of Patient Education, 337
Teaching and Learning, 337
Domains of Learning, 338
Basic Learning Principles, 339
Nursing Process, 342
26 Documentation and Informatics, 356
Noël Kerr, PhD, RN, CMSRN
Purposes of the Medical Record, 356
Interprofessional Communication Within the Medical
Record, 359
Confidentiality, 359
Standards, 361
Guidelines for Quality Documentation, 361
Methods of Documentation, 363
Common Record-Keeping Forms, 365
Acuity Rating Systems, 366
Documentation in the Home Health Care Setting, 366
Documentation in the Long-Term Health Care
Setting, 366
Documentatng Communication with Providers and
Unique Events, 366
Informatics and Information Management in Health
Care, 367
UNIT V Foundations for Nursing Practice
27 Patient Safety and Quality, 373
Michelle Aebersold, PhD, RN
Scientific Knowledge Base, 374
Nursing Knowledge Base, 376
Critical Thinking, 379
Nursing Process, 379
xviii Contents

Skill 27-1 Fall Prevention in Health Care Settings, 395 Nursing Process, 629
Skill 27-2 Applying Physical Restraints, 399 Medication Administration, 634
28 Immobility, 407 Skill 32-1 Administering Oral Medications, 655
Judith A. McCutchan, RN, ASN, BSN, MSN, PhD Skill 32-2 Administering Ophthalmic Medications, 660
Scientific Knowledge Base, 407 Skill 32-3 Using Metered-Dose or Dry Powder
Nursing Knowledge Base, 409 Inhalers, 663
Nursing Process, 413 Skill 32-4 Preparing Injections from Vials and
Skill 28-1 Moving and Positioning Patients in Bed, 432 Ampules, 666
29 Infection Prevention and Control, 442 Skill 32-5 Administering Injections, 670
Lorri A. Graham, RN Skill 32-6 Administering Medications by Intravenous
Scientific Knowledge Base, 443 Bolus, 675
The Infectious Process, 445 Skill 32-7 Administering Intravenous Medications by
Nursing Knowledge Base, 448 Piggyback, Intermittent Intravenous Infusion Sets,
Nursing Process, 449 and Syringe Pumps, 679
Skill 29-1 Hand Hygiene, 471 33 Complementary and Alternative Therapies, 688
Skill 29-2 Preparation of Sterile Field, 473 Mary Koithan, PhD, RN, CNS-BC, FAAN
Skill 29-3 Surgical Hand Asepsis, 476 Complementary, Alternative, and Integrative
Skill 29-4 Applying a Sterile Gown and Performing Approaches to Health, 688
Closed Gloving, 479 Nursing-Accessible Therapies, 691
Skill 29-5 Open Gloving, 481 Training-Specific Therapies, 693
30 Vital Signs, 486 The Integrative Nursing Role, 696
Susan Fetzer, RN, GSWN, MSN, MBA, PhD
Guidelines for Measuring Vital Signs, 487 UNIT VI Psychosocial Basis for Nursing Practice
Body Temperature, 488
Nursing Process, 491 34 Self-Concept, 701
Pulse, 497 Victoria N. Folse, PhD, APN, PMHCNS-BC, LCPC
Respiration, 500 Scientific Knowledge Base, 701
Blood Pressure, 503 Nursing Knowledge Base, 702
Health Promotion and Vital Signs, 510 Critical Thinking, 707
Recording Vital Signs, 510 Nursing Process, 707
Skill 30-1 Measuring Body Temperature, 512 35 Sexuality, 716
Skill 30-2 Assessing Radial and Apical Pulses, 517 Kathryn Lever, MSN, WHNP-BC
Skill 30-3 Assessing Respirations, 521 Scientific Knowledge Base, 716
Skill 30-4 Measuring Oxygen Saturation (Pulse Nursing Knowledge Base, 719
Oximetry), 523 Critical Thinking, 722
Skill 30-5 Measuring Blood Pressure, 525 Nursing Process, 723
31 Health Assessment and Physical Examination, 533 36 Spiritual Health, 733
Patricia A. Stockert, RN, BSN, MS, PhD
Patricia A. Potter, RN, MSN, PhD, FAAN
Purposes of the Physical Examination, 534 Scientific Knowledge Base, 733
Preparation for Examination, 534 Nursing Knowledge Base, 734
Organization of the Examination, 537 Critical Thinking, 736
Techniques of Physical Assessment, 539 Nursing Process, 737
General Survey, 541
Skin, Hair, and Nails, 544 37 The Experience of Loss, Death, and Grief, 750
Emily L. McClung, MSN, RN, PhD(c)
Head and Neck, 552
Scientific Knowledge Base, 751
Thorax and Lungs, 567
Nursing Knowledge Base, 752
Heart, 571
Critical Thinking, 755
Vascular System, 575
Nursing Process, 755
Breasts, 580
Abdomen, 586 38 Stress and Coping, 771
Female Genitalia and Reproductive Tract, 589 Matthew R. Sorenson, PhD, APN, ANP-C
Male Genitalia, 591 Scientific Knowledge Base, 771
Rectum and Anus, 593 Nursing Knowledge Base, 774
Musculoskeletal System, 595 Critical Thinking, 776
Neurological System, 598 Nursing Process, 776
After the Examination, 605
32 Medication Administration, 609 UNIT VII Physiological Basis for Nursing Practice
Amy M. Hall, RN, BSN, MS, PhD, CNE
Wendy R. Ostendorf, RN, MS, EdD, CNE 39 Activity and Exercise, 787
Scientific Knowledge Base, 609 Judith A. McCutchan, RN, ASN, BSN, MSN, PhD
Nursing Knowledge Base, 618 Scientific Knowledge Base, 787
Critical Thinking, 626 Nursing Knowledge Base, 792

Critical Thinking, 794
Nursing Process, 796
Skill 39-1 Using Safe and Effective Transfer
Techniques, 811
40 Hygiene, 821
Patricia A. O’Connor, RN, MSN, CNE
Scientific Knowledge Base, 821
Nursing Knowledge Base, 823
Critical Thinking, 825
Nursing Process, 826
Skill 40-1 Bathing and Perineal Care, 854
Skill 40-2 Performing Nail and Foot Care, 862
Skill 40-3 Performing Mouth Care for an Unconscious
or Debilitated Patient, 865
41 Oxygenation, 871
Erin H. McCalley, RN, BSN, MS, CCRN, CCNS
Scientific Knowledge Base, 872
Nursing Knowledge Base, 879
Critical Thinking, 880
Nursing Process, 880
Skill 41-1 Suctioning, 907
Skill 41-2 Care of an Artificial Airway, 915
Skill 41-3 Care of Patients with Chest Tubes, 922
Skill 41-4 Using Home Oxygen Equipment, 927
42 Fluid, Electrolyte, and Acid-Base Balance, 934
Linda Felver, PhD, RN
Scientific Knowledge Base, 935
Nursing Knowledge Base, 945
Critical Thinking, 946
Nursing Process, 946
Skill 42-1 Initiating Intravenous Therapy, 967
Skill 42-2 Regulating Intravenous Flow Rate, 977
Skill 42-3 Maintenance of Intravenous System, 981
Skill 42-4 Changing a Peripheral Intravenous
Dressing, 987
43 Sleep, 992
Patricia A. Stockert, RN, BSN, MS, PhD
Scientific Knowledge Base, 992
Nursing Knowledge Base, 997
Critical Thinking, 999
Nursing Process, 999
44 Pain Management, 1014
Maureen F. Cooney, DNP, FNP-BC
Scientific Knowledge Base, 1015
Nursing Knowledge Base, 1018
Critical Thinking, 1021
Nursing Process, 1022
Skill 44-1 Patient-Controlled Analgesia, 1046
45 Nutrition, 1053
Kristine Rose, BSN, MSN
Scientific Knowledge Base, 1054
Nursing Knowledge Base, 1058
Critical Thinking, 1061
Nursing Process, 1063
Skill 45-1 Aspiration Precautions, 1083
Skill 45-2 Inserting and Removing a Small-Bore
Nasoenteric Tube for Enteral Feedings, 1085
Skill 45-3 Administering Enteral Feedings via
Nasoenteric, Gastrostomy, or Jejunostomy
Tubes, 1090
Skill 45-4 Blood Glucose Monitoring, 1094
Contents xix
46 Urinary Elimination, 1101
Donna L. Thompson, MSN, CRNP, FNP-BC, CCCN-AP
Scientific Knowledge Base, 1101
Nursing Knowledge Base, 1106
Critical Thinking, 1107
Nursing Process, 1107
Skill 46-1 Collecting Midstream (Clean-Voided) Urine
Specimen, 1128
Skill 46-2 Inserting and Removing a Straight
(Intermittent) or Indwelling Catheter, 1131
Skill 46-3 Indwelling Catheter Care, 1140
Skill 46-4 Closed Catheter Irrigation, 1142
47 Bowel Elimination, 1149
Jane Fellows, MSN, CWOCN
Scientific Knowledge Base, 1149
Nursing Knowledge Base, 1150
Critical Thinking, 1154
Nursing Process, 1154
Skill 47-1 Administering a Cleansing Enema, 1170
Skill 47-2 Inserting and Maintaining a Nasogastric
Tube for Gastric Decompression, 1174
Skill 47-3 Pouching an Ostomy, 1179
48 Skin Integrity and Wound Care, 1184
Janice C. Colwell, RN, MS, CWOCN, FAAN
Scientific Knowledge Base, 1184
Nursing Knowledge Base, 1192
Critical Thinking, 1195
Nursing Process, 1195
Skill 48-1 Assessment for Pressure Ulcer
Development, 1221
Skill 48-2 Treating Pressure Ulcers, 1224
Skill 48-3 Applying Dry and Moist Dressings, 1226
Skill 48-4 Implementation of Negative-Pressure Wound
Therapy, 1231
Skill 48-5 Performing Wound Irrigation, 1234
Skill 48-6 Applying an Elastic Bandage, 1236
49 Sensory Alterations, 1241
Jill Parsons, PhD, RN
Scientific Knowledge Base, 1241
Nursing Knowledge Base, 1243
Critical Thinking, 1244
Nursing Process, 1245
50 Care of Surgical Patients, 1261
Antoinette Falker, DNP, RN, CMSRN, CBN, GCNS-BC
Scientific Knowledge Base, 1262
Nursing Knowledge Base, 1266
Critical Thinking, 1266
Preoperative Surgical Phase, 1267
Nursing Process, 1267
Transport to the Operating Room, 1281
Intraoperative Surgical Phase, 1282
Nursing Roles During Surgery, 1282
Nursing Process, 1282
Postoperative Surgical Phase, 1285
Immediate Postoperative Recovery (Phase I), 1285
Recovery in Ambulatory Surgery (Phase II), 1286
Postoperative Recovery and Convalescence, 1286
Nursing Process, 1286
Skill 50-1 Demonstrating Postoperative Exercises, 1297
Glossary, 1307
This page intentionally left blank

OBJECTIVES
• Discuss the development of professional nursing roles.
• Describe educational programs available for professional
registered nurse (RN) education.
KEY TERMS
Advanced practice registered nurse Code of ethics, p. 3
(APRN), p. 4 Continuing education, p. 10
American Nurses Association (ANA), p. 2 Genomics, p. 9
Caregiver, p. 3 In-service education, p. 10
Certified nurse-midwife (CNM), p. 4 International Council of Nurses (ICN),
Certified registered nurse anesthetist p. 2
(CRNA), p. 4 Nurse administrator, p. 5
Clinical nurse specialist (CNS), p. 4 Nurse educator, p. 4
MEDIA RESOURCES
http://evolve.elsevier.com/Potter/fundamentals/
• Review Questions
• Case Study with Questions
Nursing is an art and a science. As a professional nurse you will learn
to deliver care artfully with compassion, caring, and respect for each
patient’s dignity and personhood. As a science, nursing practice is
based on a body of knowledge that is continually changing with new
discoveries and innovations. When you integrate the art and science of
nursing into your practice, the quality of care you provide to your
patients is at a level of excellence that benefits patients and their
families.
NURSING AS A PROFESSION
A variety of career opportunities are available in nursing, including
clinical practice, education, research, management, administration,
and even entrepreneurship. As a student it is important for you
to understand the scope of professional nursing practice and how
nursing influences the lives of your patients, their families, and their
communities.
The patient is the center of your practice. Your patient includes
individuals, families, and/or communities. Patients have a wide variety
of health care needs, knowledge, experiences, vulnerabilities, and
expectations; but this is what makes nursing both challenging and
rewarding. Making a difference in your patients’ lives is fulfilling (e.g.,
helping a dying patient find relief from pain, helping a young mother
learn parenting skills, and finding ways for older adults to remain
independent in their homes). Nursing offers personal and professional
rewards every day. This chapter presents a contemporary view of the
evolution of nursing and nursing practice and the historical, practical,
social, and political influences on the discipline of nursing.
1
Nursing Today
• Describe the roles and career opportunities for nurses.
• Discuss the influence of social, historical, political, and economic
changes on nursing practices.
Nurse practitioner (NP), p. 4
Nurse researcher, p. 5
Nursing, p. 2
Patient advocate, p. 3
Professional organization, p. 10
Quality and Safety Education for Nurses
(QSEN), p. 7
Registered nurse (RN), p. 9
• Audio Glossary
• Content Updates
Nursing is not simply a collection of specific skills, and you are not
simply a person trained to perform specific tasks. Nursing is a profes-
sion. No one factor absolutely differentiates a job from a profession,
but the difference is important in terms of how you practice. To act
professionally you administer quality patient-centered care in a safe,
prudent, and knowledgeable manner. You are responsible and account-
able to yourself, your patients, and your peers.
Health care advocacy groups recognize the importance of the
role quality professional nursing has on the nations’ health care. One
such program is the Robert Wood Johnson Foundation (RWJF) Future
of Nursing: Campaign for Action (RWJF, 2014a). This program is a
multifaceted campaign to transform health care through nursing, and
it is a response to the Institute of Medicine (IOM) publication on The
Future of Nursing (IOM, 2010). Together these initiatives prepare a
professional workforce to meet health promotion, illness prevention,
and complex care needs of the population in a changing health care
system.
Science and Art of Nursing Practice
Because nursing is both an art and a science, nursing practice requires
a blend of the most current knowledge and practice standards with an
insightful and compassionate approach to patient care. Your patients’
health care needs are multidimensional and constantly changing. Thus
your care will reflect the needs and values of society and professional
standards of care and performance, meet the needs of each patient, and
integrate evidence-based findings to provide the highest level of care.
Nursing has a specific body of knowledge; however, it is essential
that you socialize within the profession and practice to fully
1
Another random document with
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room—Mother Mary Monica, at her own earnest request,
being allowed to remain with us and oversee our
proceedings. We began with a good washing and combing
all round (not a nice piece of work by any means), and then
dressed them in clean clothes, of which we had a plenty by
us made up for our regular autumn doles. The dear old
Mother was as pleased as a child with a new doll. I can't say
the same for the poor children, who were strange, and
scared, and at first hardly to be pacified; but by degrees
they seemed to find the comfort of being clean, and by
night they were all merrily at play, as if nothing had
happened to them. We made up as many cot beds as there
were children, and my own bed was moved into the room.
Sister Anne also slept in the room till she was taken sick,
when Amice was allowed to take her place.

I don't think, for my own part, that I was ever happier than
when playing with these children, or teaching them their
hornbook and the use of their little fat fingers. The oldest is
about ten, a wise motherly little maid, and a great help to
us with the others. The youngest is only three—the sole
survivor of Roger Smith's family. Considering what the
family was like, we may hope her loss may prove a gain.

There were many different opinions in the house concerning

the sheltering of these orphans. Sister Catherine, who has
not had so much to say about discipline since her dismissal
from office, opened her mouth once more to protest against
the great irregularity of our taking the babes, and the utter
impropriety of their being committed to the care of the
youngest person in the house. But Sister Placida, who is
great in the history of this and other orders, and who has
no objection (or so I think) to putting down Sister
Catherine, brought so many precedents to bear against her,
that she was fain to betake herself to her humility, her usual
refuge when worsted. Some were terrified at the notion of
bringing infection into the house; but in general, I must say,
the Sisters were very kind to the poor children, and very
glad of an excuse to slip away, and play with them.

It was two weeks after the pestilence broke out in the

village before it appeared in the house. Sister Bridget was
the first victim. She was taken in the night, with the heat
and sweat, and, poor creature, had no more wit than to rise
and stand for half an hour or more at the open window of
her cell, till Mother Gertrude, making her rounds,
discovered her state. She was taken at once to the
infirmary, and died in a few hours, very happy and
resigned, and saying, with almost her last breath, poor
thing, that everybody had been very kind to her. From that
time we had a new case or two every day for a week.
Almost every one who had resolution enough to remain
quietly in bed and bear the all but intolerable discomfort of
the heat and bad odor, recovered; but many were light-
headed, and unless watched every moment, would throw off
the clothes and otherwise expose themselves: and every
one who got the slightest chill died without remedy.

It was a trying time, and one which showed what people

were made of; for the discipline of the family was
necessarily much relaxed, the care of the sick being the
principal matter, and each one showed in her true colors—
very unexpected colors some of them have been. Mother
Gabrielle, who has always been rather fussy and fidgetty,
and especially apt to be scared on small occasions, and to
fret over little accidents and losses, was as calm and
cheerful as a summer morning, till she was taken down
herself, when she made a most edifying end. Mother
Superior, though calm and composed, was very sad. Mother
Gertrude, just as usual.
In general I must say the Sisters have behaved very well.
Sister Catherine was the most alarmed of anybody, and
made herself rather a trouble by going round asking
everybody's pardon and wanting to kiss their feet, which
was not always quite convenient when one had a jug of
barley water, or a crying babe in one's arms. She wanted to
help in the infirmary, but she cried so, and was besides so
unwilling to obey orders without some little variation of her
own, that Sister Placida dispensed with her help very
suddenly. At last she took to her own bed with a kind of
nervous fever; and as she was not very sick, everybody was
rather glad to have her out-of-the-way.

Sister Mary Paula was quite different. From the first she
attended steadily to her work, speaking but little, but very
kind and sober in her demeanor. One morning, when I went
to the kitchen for the children's dinner, at ten o'clock, she
stopped me.

"Rosamond, did you know who it was told the Bishop of

your sending a love token to your cousin?"

"Nay!" said I. "I had not an idea, nor do I wish to know,

since no harm has come of it."

"Well, it was I!" said she, bluntly, turning scarlet as she

spoke. "My brother is the Bishop's chaplain, and when he
came to see me, I managed to slip a note into his hand,
telling him the whole story, as I had heard it!"

"But, dear Sister, how could you do that, since yourself told
me you could not write?" I asked, in amazement.

"I did not write it—that was done by another hand!" she
answered me. "But 'twas I conveyed it to my brother. I
fancied, or tried to fancy, that I was moved by zeal for
religion and for the honor of this house; but my eyes have
been opened lately, and I see things more clearly. 'Twas
mere spite and envy, because I thought you a favorite. I
desired to bring you into disgrace, or to cause your removal
from the house; and I beg your pardon."

"I am sure you have it, with all my heart!" said I, kissing
her. "Nay, there is naught to pardon, since all turned out to
my advantage at last."

"Yes, the stones we threw returned on our own heads!" she

answered. "And so they ought. Here, take these cakes for
your brats. Do they all keep well?"

"All!" I told her, but added that she did not look well herself,
and I feared she was working too hard.

"Nay, I am well enough," she said, "but Rosamond, will you

pray for me? My mind is distracted with all this work and
worry, and I fear my prayers are of little value."

I told her I did not believe such distraction hurt our prayers,
and reminded her of what Father Fabian had said about
offering our work and our very distractions. She kissed me
again and I went my way. That was the last time I ever saw
her alive. She dropped that evening in the chapel, and died
before midnight. It seemed the signal for a new outbreak of
the disease. Three of my charge were attacked, and two
died, and of the Sisters, three within the next three days.
Mother Gabrielle was the last, and I do think she died as
much as anything from sheer fatigue. I had no touch of the
disorder, though I nursed all the children who had it, and
also Sister Anne, whom we hoped at one time might
recover; but she had a relapse, I think from getting up too
soon, despite the warnings of Mother Mary Monica.

Now things have returned to their usual course, save that

with the Bishop's approbation, we have kept the three
children who survived, and have also taken in two more.
Amice and I have the charge of teaching and overseeing
them, under the real superintendence of Mother Gertrude
and the nominal care of Mother Mary Monica, which mostly
consists in telling them stories, cutting out figures, and
begging off from pains and penalties. What a dear old
grandmother she would have made!

I have heard but once from my friends in London, who are

all well. My father is coming home in a few weeks.

CHAPTER XVII.

October 28.

AMICE, is sick—I don't know what ails her, but she has been
growing thin and pale ever since the pestilence, and now
she has been obliged to take to her bed. She does not
suffer much, save from her weakness, which so affects her
nerves that she can hardly bear any one in the room with
her, but prefers to stay alone. The doctor says she is to
have her way in all things—a sentence which always sounds
to me like that of death. My heart is like to break with the
thought, but there is no help. Nobody will ever know what
she has been to me.

CHAPTER XVIII.

All Saints' Day, Nov. 2.

IT seems as if there were never more to be peace in this

devoted house. Magdalen Jewell, the woman who lived at
Grey Tor, the woman who nursed her neighbors all through
the sickness, and has since been a mother to many an
orphan, and a dutiful daughter to many a widow, Magdalen
Jewell is accused of heresy, apprehended, and shut up in
Saint Ethelburga's vault, till she can be removed to a
stronger prison. 'Tis a shame, and I will say it. They have
no business to put such an office on us, but Father Fabian,
who, I do suspect, likes the business no more than I do,
says 'tis done in hopes that the persuasions of himself and
Mother Superior may bring her to a better mind. They say
there is no doubt of her guilt.

Indeed, she herself denies it not, but glories in it, and is full
of joy. I heard her myself singing of some hymn, as I
judged. They say she was suspected a long time, and a man
whom she had nursed in the sickness, spying upon her at
night through the window, saw her many times reading in a
great bound book she had. He giving information, the house
was searched, and the book found. It proved to be a copy of
the Scriptures in the vulgar tongue. Magdalen being
apprehended, showed neither surprise nor fear, but
confessed all, and gloried, as she said, that she was
counted worthy to die for her religion. And now she is shut
up in that horrible place, and Mother Gertrude—she who
has always seemed too kind to hurt a fly, is her keeper, and
unless she recants she must needs be burned. It is utterly
horrible!

And they are all so hard-hearted against her! Father Fabian

says it is a sin to pity a heretic, and so say all the Sisters.
Even Mother Gertrude, though she offers many prayers for
her conversion, says she deserves her fate, and even that
the man who betrayed her did a good deed, in thus laying
aside all the ties of natural affection. But I cannot think so.
The man seems to me a horrible wretch and traitor, far
more deserving of the stake than this good, kind woman,
who has sacrificed everything to her neighbors.

My whole mind is in a tumult, and for the first time I feel as

if I would give anything to leave the shadow of this roof and
never see it again. And that dear old chapel, that I so loved,
and where I had such sweet comfort, to be so used! I
cannot write nor even think. I would Amice were well, but
she is more feeble than she has been, and last night she
begged that Mother Gertrude might sleep in the room with
her, though she would not have her sit up.
 CHAPTER XIX.

Nov. 4.

MAGDALEN JEWELL hath escaped, at the least she hath

disappeared, and no one knows what has become of her. It
seems impossible that she could have got out, as there are
no means whatever of opening the door from the inside,
and the key hath never left Mother Gertrude's care. Some
of the Sisters think that the ghost or demon, or whatever it
is that hath heretofore avenged sacrilege in that chapel,
hath torn her in pieces and carried her off bodily, but they
say there are no signs of any such struggle. The very cruse
of water which Mother Gertrude carried to the prisoner last
night is standing half emptied on the floor, but the bread is
all gone, so she must have eaten her supper.

Mother Gertrude, on rising, found poor Amice very much

worse, faint and exhausted, which delayed her a little.
When she went to the prison, she called as usual, but there
was no answer. She looked through the grating in the door,
usually masked by a panel on the outside, but could see
nothing. Becoming scared, she sent for Mother Superior and
Father Fabian, who had the tower and vault thoroughly
searched, but nothing was to be found, save what had
always been there. It is a most wonderful chance. I don't
think Father Fabian believes very much in the demon, or he
would not have searched the grounds so carefully, or asked
so many questions. Mother Gertrude takes charge of all the
keys at night, and places them under her pillow; and beside
that, who was to steal them, supposing that such a theft
were possible? Mother Gertrude is a heavy sleeper, but
Amice is a very light one, specially since her illness, and she
declares most positively, that she is certain nobody was in
the room last night, save herself and Mother Gertrude.

It is all a dark mystery. Magdalen was to have been

removed to Exeter to-day, but now Father Fabian must go
instead, and give the best account he may of the matter. I
cannot say that I believe very much in the demon, any
more than Father Fabian. My notion is that some friend from
outside hath found a way of helping the poor woman, or
that there is some way of escape from the tower which we
know not of.

Anyhow, I am glad she is gone, and so I can't but think

there are some others, if they would say so. The tower
being open, some of us young ones ventured to explore it,
and even into the vaults below. The tower is simply what it
looks to be—a structure of great unhewn stone, with
projections here and there like shelves, and the remains of
a stone staircase, though where it should lead to I cannot
guess. Another stone stairs leads down to the vault, which
is perfectly dark, save for one narrow slit at the very top,
going into the garden. Here was once a shrine, whereof the
altar and crucifix still remain. A row of niches runs all
round, of which two have been built up, doubtless for burial
purposes, and there are the dusty remains of several
coffins, such as are used for nuns, beside two or three of
lead and stone. 'Tis a dismal and dreadful place, and it
seems horrible to think any living being should be confined
there. Yet, the story goes that it has sometimes been used
as a prison for nuns guilty of grave offences.

I drew a long breath, when I got into the free air of heaven
once more, and I must say, I was glad to think poor
Magdalen had escaped.

I could be as light-hearted as a bird, only that my dear

Amice is so much worse. She is very low indeed, too
exhausted to speak; but she lies quietly in her bed, with a
look of most heavenly peace on her face. She seems most
of the time engaged in inward prayer and thanksgiving, for
her eyes are closed and her lips move, and now and then
she opens her eyes with such a wondrous smile, as if she
saw the glories of heaven open before her. What shall I do
when she is gone? I dare not think. I have been sitting by
her a great part of the day, and now Mother Gertrude tells
me, she has asked that I may watch beside her this night,
and dear Mother hath given permission. I am most thankful
for the privilege, for I would not lose one moment of her
dear society.
 CHAPTER XX.

Nov. 8th.

AMICE CROCKER, my dearest friend, is dead and buried—

buried in a dishonored grave, by the poor lady who was
prisoner in the Queen's room so long. She died a heretic,
they say, without the sacraments, and they tell me it is
sinful in me to love her longer. But I will love her, to the
latest day of my life. I don't believe she is lost either, and
nothing shall ever make me think so. Oh, that last night
when I sat by her side, and she told me all!

Well, she is gone, and naught can hurt her more. I think
Mother Gertrude will soon follow, for she seems utterly
broken down. She might well say that no good would come
of the Queen's visit. And if Amice should be right, after all,
and we wrong! I must not, I dare not think of it! Alack and
woe is me! I would I had died in the sickness, or ever I had
lived to see this sorrowful day!
 CHAPTER XXI.

Corby End, April 20, 1530.

I LITTLE thought, a year ago, that another April would see

me quietly at home in my father's house, and with such a
companion—still less that I could be quite content in such a
companionship. If any one had told me so, I should have
laughed or been angry, I hardly know which, and yet I am
quite ready to confess that 'tis all for the best.

My father, my Lady and Harry are all gone to make a visit at

Fulton Manor, where is now much company to celebrate the
wedding of Sir Thomas' eldest daughter. I was to have gone
with them, but when the day came the weather was damp
and cold; and as I am only just beginning to be strong
again, my Lady and I both thought I should be better at
home. Father and Harry were much disappointed, and I saw
Harry was a little disposed to lay the blame on my Lady, but
a little quiet reasoning and some coaxing finally made him
own that all was for the best. So here I am, in sole
possession of the house, and for the first time I have got
out my book of chronicles.

I have read it all over, and pasted in the loose leaves where
they belong, as even should I return to the convent I shall
not take it with me. I am minded to continue it, especially
as I can now write freely and without concealment. My
stepmother never interferes in my private matters. Even
Mrs. Prue, who began by attributing to her almost every
fault of which woman is capable, now grudgingly admits
that my Lady minds her own business, and is passing good-
natured. In fact, only for that one mortal sin of marrying my
father, I think the old woman would allow her new lady to
be a mistress of good conditions.

I suppose I had better begin just where I left off.

The night before Amice died, she begged that I alone might
sit with her, saying that Mother Gertrude needed unbroken
rest, which was true. Amice was so manifestly near her end
that Mother Superior did not like to refuse her anything,
and Mother Gertrude somewhat unwillingly gave way. The
dear Mother would have spent the whole night in prayer for
her niece at the shrine of St. Ethelburga, had not Mother
Superior laid her commands on her to go to bed and rest all
night.

"Sit close by me, dear Rosamond," said Amice, "you know I

cannot speak loud now, and I have much to say."

"You must not tire yourself by talking," said I.

"It will make no difference," she answered.

"I feel that my end is very near. Doubtless what I did last
night may have hastened my death, but I do not regret it; I
would do it again."

"What you did last night!" I repeated, struck with a sudden,

most strange thought. "Do you mean, Amice, that you—" I
could not finish the sentence.

"Hush!" said she. "Even so, Rosamond. I took the keys from
under Mother Gertrude's pillow (you know how sound she
sleeps, especially when she has been disturbed), opened
the doors and let the prisoner free."
"But the outer door—that heavy iron door!" I exclaimed, in
amazement.

"I did not open the outer door. She climbed over the wall
there by the beehives. The gardener had left his ladder
close by. I wonder they did not find it in the search this
morning."

"I dare say he had taken it away before that he might not
be blamed for his carelessness," said I. "But Amice, even
then I see not how you accomplished it. We have thought
you so weak."

"And so I have been," said she. "The day before, I could

hardly rise without help, and after I got back to my bed, I
lay for many hours so utterly exhausted that I many times
thought myself dying. But at least I had the strength to call
nobody, for I wished above all things that Magdalen might
have time to escape. She told me at parting that with three
hours' vantage, she would defy even the King's
bloodhounds to find her; and I was determined she should
lose that vantage through no fault of mine."

"But, if you had died, Amice—died without confession and

the sacraments," said I. I knew that she had not confessed
for a long time, putting off the Father by saying she was too
weak, and that it hurt her to talk.

"I should not have died without confession, dearest

Rosamond," said she, with an heavenly smile. "I have
known this many a day that there needs no priest to make
a confession valid, but that to every truly penitent heart the
way to the very throne of Heaven is open, and that the
blood of Jesus Christ cleanseth from all sin. If I regretted
aught, it was that I must die without another kind of
confession—the confessing my faith openly before men. I
have longed to do so, but I shame to say it—I have been
afraid. But now I fear no longer."

I was utterly dumbfounded, and could not speak a word.

"Shall I tell you the whole?" she asked, presently. "Or are
you too much shocked to hear more? You will not cast me
off, will you, Rosamond?"

"Never!" said I, finding my voice at last. "But, dearest

Amice, consider. Think of your fair fame—of Mother
Gertrude and dear Mother Superior!"

"I have thought of all," she answered; "yea, many times

overt and though I grieve to grieve them, yet I must needs
speak. I have denied Him before men too long already: I
must needs confess Him before I die, come what may. Give
me some cordial, Rosamond. I must keep myself up till to-
morrow, at least."

I gave her the cordial, and after a little rest, she began once
more:

"Rosamond, do you remember the day we were dusting the

chairs in the Queen's room, and you showed me one, the
velvet whereof was spotted with small spots, as of drops of
water? Mother Gertrude sent you to the wardrobe just
then."

"I remember it well," I answered; "and that looking from

the window I saw you reading some ragged leaves which
you put into your bosom. I meant to ask what they were,
but in the multitude of business, I forgot."

"Exactly so!" said Amice. "I was dusting the chair, and on
taking up the cushion, which I found to be moveable, there
fell out these leaves. I took them up to read them, thinking
they might throw some light on the poor lady's history, but
I had read little when I knew what I had found—something
I had long desired to see. It was a written copy of the
Gospel of St. John, done into English. Doubtless the poor
prisoner had managed to bring it with her, and had found a
convenient hiding-place for her treasure in this chair, which
she had watered with her tears."

"I had read but a few words when I was interrupted; but
those words were engraven on my mind as with a pen of
steel. They were these: 'God so loved the world that he
gave his only son for the intent that none that believe in
him should perish, but should have everlasting life. For God
sent not his son into the world to condemn the world, but
that the world through him might be saved.'"

"Rosamond, I was as a man walking through desolate

moors and among quaking bogs and thorny thickets, to
whom a flash of light from Heaven showed for one moment
the right and safe road. It was but a glimpse. I had no more
time to read then, nor for some hours after; but that night,
in recreation, I did find time for a few more verses. By the
first peep of light next morning I was up and at my window,
and thenceforth the morning star seldom found me
sleeping. I placed the book of the Gospel inside my prayer-
book, for better concealment, but after I had once read it
through, and for fear it might be taken from me, I learned it
all off by heart."

"I remember how we used to smile at your early rising,"

said I; "we little thought what you were about."

"This went on for a while," continued Amice, (I set down her

own words as near as I can remember them): "and then I
came near a discovery. You know how light of foot was
Mistress Anne. Well, one day, when I had ventured, as I
seldom did, to take out my book while I was waiting in the
Queen's anteroom, she came behind me and peeped over
my shoulder, and before I could hinder, snatched the leaves
from my hand. I thought then that all was lost; but after
teasing me awhile in her childish fashion, she gave me back
my treasure, and said she would get me a better book than
that, even the whole New Testament, done into fair English
by one Master Tyndale."

"But mind!" she added, "I don't stand sponsor for all his
notions, and I wont be answerable for the consequences to
yourself. This much I may say. 'Twas a very learned and
good man gave me the book, and he says 'tis true to the
original Greek, out of which it was translated by Master
Tyndale."

"And have you read it?" I asked her.

"Not I," says she, "save only a chapter, here and there; but
let me tell you, Mistress Amice, if this book gains ground, as
'tis like to do, your priests and nuns and mitred abbots will
fly away like ghosts and owls before the sunrising. Nay,
unless some I know are the more mistaken, the cock has
crowed already."

"That very night she gave me the book, and before she left,
she added another which was sent her from London, namely
Master Tyndale's exposition of certain passages. But I cared
not so much for that, as for the other. Then came the
sickness, when the discipline of the house being so much
relaxed, I had more time to read and study and compare.
Rosamond, how amazed was I to find that there is in the
New Testament no single hint of any worship being paid to
our Lord's mother—nay, our Lord Himself saying, that those
who did His Father's will, were even to Him as His own
mother."
"'Tis not the right Gospel," said I. "Why Amice, only think
how our Lady is honored throughout all Christendom.
Depend upon it, you have been deceived."

"Who would dare to carry out such a deception?" said she.

"Every learned man in Christendom would be against him."

I cannot now write down all she said, as how she had found
the teaching of our Lord so much more simple and plain,
than those in the lives of the saints—how Himself had
declared that whosoever did but believe on Him, had
already everlasting life—how Christ being already offered
for sin, there was no more sacrifice, but all was perfected in
Him; and much more which I did not, and do not yet
understand. But she ended by saying, that she could no
longer keep silence, since the Lord had commanded all to
confess Him before men, and had declared that He would
deny all who did not thus confess Him.

"I cannot die with a lie on my lips," she said. "I dare not
thus go into the presence of my God, where I must soon
stand; for God doth hate lying above measure, inasmuch as
He hath declared that all liars shall have their part in the
second death. Besides, were it not utterly base to deny
Him, who hath done and will do so much for me?"

I used many arguments with her, but could prevail nothing,

even when I spoke of Mother Gertrude and her sorrow, at
which Amice wept so vehemently, that I was alarmed; but
when she was again composed, she said she had thought of
that many times, and with many prayers and tears, but yet
she could see her duty in no other way.

Oh, I cannot tell all she said. I would I could remember and
set down every word, but much has gone from me. She
bade me take comfort concerning her, when she was gone,
saying that nothing they could do would work her any real
injury. She told me how happy her new faith had made her,
despite many perplexities concerning her duty—how at the
last she had seen her way clear, and what peace she had
felt in the thought that her free salvation had been provided
for in Christ, and she had but to believe, and be saved.

"What, even if you were wicked?" said I.

"Don't you see, dear Rosamond, that one who really

believed in our Lord could not be wicked? If he really and
truly believed that the Lord died for him, he would desire to
do what that Lord commanded, and to be like Him. He
would know that Christ makes keeping His commands the
very test of faith and love, even as He saith: 'He that hath
my commands and keepeth them, He it is that loveth me.'"

I asked what she had done with her Testament, and she
told me she had given it to Magdalen Jewell, knowing that
she should need it no longer.

"There are many things therein which I don't understand,

but they will soon be made plain," said she. "Is it not
almost morning, Rosamond? Draw the curtain and see."

I did so. Lo the dawn was stealing on, and in the east
shone, glorious to see, the morning star.

"There is the emblem of my Lord!" said Amice, clasping her

hands; "There is the bright and morning star. It is the last
dawning I shall see on earth! To-morrow. Rosamond, and
whenever you think of me, remember that I am resting
where there is no need of sun or moon: 'For the brightness
of God did lighten it, and the Lamb was the light of it.' 'They
shall hunger no more neither thirst any more, neither shall
the sun light on them nor any heat. For the Lamb which is
in the midst of the seat shall feed them and shall lead them