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Physical Therapy Management
Chapter17. Physical Therapy Considerations for Patients Who Present With Chest Pain
Introduction
Physiology of Chest Pain
Presentation of Chest Pain
Diagnostic Considerations
Physical Therapy Considerations
Part 4. Interventions
Chapter 18. Medical-Surgical Equipment in the Acute Care Se ing
Introduction
Appendix 18A:. Mechanical Ventilation
Appendix 18B:. Mechanical Circulatory Support Devices
Chapter 19. Pharmacologic Agents
Introduction
Cardiovascular System
Respiratory System
Musculoskeletal System
Central Nervous System
Oncology
Vascular System and Hematology
Gastrointestinal System
Genitourinary System
Infectious Disease
Endocrine System
Organ Transplantation
Chapter20. Anesthesia: Considerations for the Physical Therapist
Introduction
Types of Anesthesia
Intraoperative Effects of Anesthesia
Postoperative Effects of Anesthesia
Operative Positioning
Chapter 21. Acute Pain Management
Introduction
Pain Evaluation
Pain Management
7
Chapter 22. Airway Clearance
Introduction
Methods of Airway Clearance
Pharmacologic Breathing Treatments
Creating an Airway Clearance Program
Chapter 23. Outcome Measures
Introduction
Berg Balance Scale
Gait Speed
Timed Up and Go Test
Dynamic Gait Index
Tinetti Performance-Oriented Mobility Assessment
Sit-to-Stand Tests
Acute Care Index of Function
Function in Sitting Test
Exercise Testing
Six-Minute Walk Test
Self-Paced Walk Test
Activity Measure For Post–Acute Care “6 Clicks” Inpatient Short Form
Intensive Care Unit–Specific Outcome Measures
Confusion Assessment Method for the Intensive Care Unit
Intensive Care Unit Mobility Scale
Functional Status Score for the Intensive Care Unit
Perme Intensive Care Unit Mobility Score
Physical Function in Intensive Care Test—Scored
Conclusion
Appendix 23A: Functional Tests
Index
8
Copyright
Elsevier
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ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS, FIFTH EDITION ISBN: 978-0-323-63919-4
Copyright © 2020 by Elsevier Inc. All rights reserved.
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Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
9
Contributers
Laura A.H. Blood, PT, DPT , Board-Certified Clinical Specialist in Geriatric Physical Therapy (GCS), Senior Physical
Therapist, Home Care Rehabilitation Services, Private Care Therapies, PLLC;, Part-Time Lecturer, Department of Physical
Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, Massachuse s
Sean M. Collins, PT, ScD

Professor & Program Director, Physical Therapy, Plymouth State University, Plymouth, New Hampshire;
Editor-in-Chief, Cardiopulmonary Physical Therapy Journal;, Adjunct Professor, Biomedical Engineering, University of
Massachuse s—Lowell, Lowell, Massachuse s
Konrad J. Dias, PT, DPT , Board-Certified Clinical Specialist in Cardiovascular and Pulmonary Physical Therapy (CCS),
Associate Professor, Physical Therapy, Maryville University of St. Louis, St. Louis, Missouri
Margarita V. DiVall, PharmD, MEd , Associate Dean, Bouvé College of Health Sciences;, Clinical Professor, School of
Pharmacy, Northeastern University, Boston, Massachuse s
Laura C. Driscoll, PT, DPT , Board-Certified Clinical Specialist in Geriatric Physical Therapy (GCS), College of Health and
Rehabilitation Sciences: Sargent College, Department of Physical Therapy & Athletic Training, Boston University, Boston,
Massachuse s
Karen Jeanne Hutchinson, PT, MS, DPT, PhD , Clinical Associate Professor, Department of Physical Therapy & Athletic
Training, Boston University, Boston, Massachuse s
David M. Krause, PT, DPT , Physical Therapist II, Physical Medicine and Rehabilitation, University Medical Center,
Lubbock, Texas
Harold Merriman, PT, PhD, CLT , Associate Professor, Department of Physical Therapy, University of Dayton, Dayton,
Ohio
Lauren Mitchell, PT, DPT , Physical Therapist II, Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore,
Maryland
Clare Nicholson, PT, DPT , Board-Certified Clinical Specialist in Cardiovascular and, Pulmonary Physical Therapy (CCS),
Clinical Team Leader Med Surg, Cleveland Clinic Rehabilitation & Sports Therapy, Cleveland Clinic, Cleveland, Ohio
Ma hew Nippins, PT, DPT , Board-Certified Clinical Specialist in Cardiovascular and, Pulmonary Physical Therapy (CCS),
Assistant Clinical Professor, Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University;,
Senior Physical Therapist, Massachuse s General Hospital, Boston, Massachuse s
Marka Gehrig Salsberry, PT, DPT , Clinical Faculty, Physical Therapy, The Ohio State University, Columbus, Ohio
Julie Anna Snyder, PT, DPT , Acute Care Physical Therapist, Rehabilitation Services, University Hospitals Ahuja Medical
Center, Beachwood, Ohio
Erin M. Thomas, PT, DPT , Assistant Professor of Practice, Physical Therapy, The Ohio State University, Columbus, Ohio
Alysha Walter, PT, DPT , Board-Certified Clinical Specialist in Cardiovascular and, Pulmonary Physical Therapy (CCS),
Assistant Clinical Professor, Physical Therapy Program, School of Behavioral and Health Sciences, Walsh University, North
Canton, Ohio
Adam B. Woolley, PharmD, MEd

Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachuse s;
Clinical Pharmacist, Department of Pharmacy, VA Boston Healthcare System, West Roxbury, Massachuse s
Contributors to Previous Editions
Cathy S. Elrod, PhD, PT , Chair and Associate Professor, Department of Physical Therapy, Marymount University,
Arlington, Virginia
James J. Gaydos, MS, PT , Senior Physical Therapist, Department of Inpatient Acute Care, New England Baptist Hospital,
Boston, Massachuse s
10
Jennifer Lee Hunt, MS, PT , Physical Therapist, Rehabilitation Services, Lahey Clinic, Burlington, Massachuse s
Marie Jarell-Gracious, PT , Owner, Specialty Care, Mokena, Illinois
Burns and Wounds
Kimberly Knowlton, PT , Clinical Lead Physical Therapist, Rehabilitation Services, University of Massachuse s Memorial
Medical Center, Worcester, Massachuse s
Burns and Wounds
Eileen F. Lang, PT, DPT , Senior Physical Therapist, Rehabilitation Services, Lahey Clinic North Shore, Peabody,
Massachuse s
Medical-Surgical Equipment in the Acute Care Se ing
V. Nicole Lombard, MS, PT , Staff Physical Therapist, Department of Physical Therapy, New England Baptist Hospital,
Infectious Diseases
Rachael Maiocco, MSPT , Physical Therapist, Brigham and Women’s Hospital, Boston, Massachuse s
Infectious Diseases
Cheryl L. Maurer, PT , Senior Physical Therapist, Outpatient Physical Therapy Services, Massachuse s General Hospital,
Leah Moinzadeh, PT , Physical Therapist, Inpatient Rehabilitation, Rehabilitation Services, Lahey Clinic, Burlington,
Massachuse s
Jackie A. Mulgrew, PT, CCS , Clinical Specialist, Physical Therapy Services, Massachuse s General Hospital, Boston,
Massachuse s
Circulatory Assist Devices
David Nicoloro, PT, MS

In-Patient Physical Therapy Coordinator, Department of Rehabilitation Services, Newton-Wellesley Hospital, Newton,
Massachuse s
Clinical Instructor, Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston,
Massachuse s
Gastrointestinal System
Kara O’Leary, MS, PT, CCS , Senior Physical Therapist, Inpatient Physical Therapy and Outpatient Pulmonary
Rehabilitation, Rehabilitation Services, Lahey Clinic, Burlington, Massachuse s
Pulmonary System
Susan Polich, PT, MA (ASCP), MEd
Assistant Clinical Specialist, Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University,
Adjunct Instructor, Physical Therapy Assistant Program, Community College of Rhode Island, Newport, Rhode Island
Oncology, Fluid and Electrolyte Imbalances
Danika Quinlan, PT, DPT , Staff Physical Therapist, Dayton VA Medical Center, Dayton, Ohio
Acute Pain Management
Jason D. Rand, PT
Physical Therapist, Inpatient Physical Therapy Services, Winthrop University Hospital, Mineola, New York
Amputation
Marie R. Reardon, PT , Clinical Specialist, Inpatient Physical Therapy Services, Massachuse s General Hospital, Boston,
Massachuse s
11
Hillary A. Reinhold, DPT, CBIS , Senior Physical Therapist, Inpatient Complex Medical, Spaulding Hospital–Cambridge,
Cambridge, Massachuse s
Nervous System
Paul E.H. Ricard, PT, DPT, CCS
Clinical Specialist, Rehabilitation Services, Brigham and Women’s Hospital, Boston, Massachuse s
Adjunct Faculty, Physical Therapy, University of Massachuse s–Lowell, Lowell, Massachuse s
Part-Time Lecturer, Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston,
Massachuse s
Functional Tests
Jennifer A. Silva, MS, PT , Physical Therapist, Outpatient Rehabilitation Center, South Shore Hospital, South Weymouth,
Massachuse s
Functional Tests
Timothy J. Troiano, PT , Senior Physical Therapist, Outpatient Physical Therapy Services, Massachuse s General Hospital,
Oncology
Falguni Vashi, PT, DPT , Physical Therapist, Rehabilitation Services, St. Joseph Hospital, Nashua, New Hampshire
Vascular System and Hematology
Karen Vitak, PT, DPT , Clinical Assistant Professor, Director of Clinical Education, School of Health Sciences, Cleveland
State University, Cleveland, Ohio
Jessika Vizmeg, PT, DPT , Staff Physical Therapist, St. Vincent Charity Medical Center, Cleveland, Ohio
Endocrine System
Kelsea A. Ziegler, Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, Massachuse s
Pharmacologic Agents
12
Dedication
To Nay and Tay—my gratitude for a life full of blessings.
To Tallie, Will, and Henry—my joy and my life.
J.C.P.
For Isabelle and Genevieve, my sunshine!
For Amy Deck and Meredith King—you are champions, steadfast and true.
For all the busy, hard-working, and devoted moms.
M.P.W.
For Michael, Ariana, and Luca—thank you for the craziness you bring to life and to the many adventures we have ahead of us.
K.P.
For my husband, Jonathan, who inspires me to educate and lead each day, and to my children, Alex and Hannah, who share how they
see the world through their eyes and seek to make change in the world.
For all the present and past students, faculty, and classmates that provide me the privilege to teach and to learn alongside them.
K.C.G
13
Preface
In the early 1990s a handful of clinicians from Massachuse s General Hospital in Boston, Massachuse s, sought to develop a
resource they believed was needed in the acute care se ing. With good fortune, a connection was made with Bu erworth-
Heinemann, and the first edition of the Acute Care Handbook for Physical Therapists was published. Twenty-two years later, with
Elsevier, the fifth edition of the Acute Care Handbook for Physical Therapists has now published. Many ideas with lots of energy
were directed toward this project. Initially, the goal was to provide clinicians with a handy, pocket-sized reference for patient
care in the hospital se ing. It was created primarily for physical therapy students and clinicians unfamiliar with entry-level
acute care practice. This handbook was never intended to be a formal comprehensive textbook; however, over the past four
editions it has evolved to become one of the resources available to students and physical therapists seeking information for this
content area.
Throughout the past 5 years, peer-reviewed literature and clinical resources related to acute care physical therapy practice
have grown tremendously. Several efforts have been successfully undertaken by collective stakeholders to maximize patient
outcomes and patient safety within the acute care se ing, resulting in position papers and references to help enhance practice
in real time. Many of the updates in this edition incorporate these advances pertinent to the evolution of the care of patients in
the acute care environment as well as developments in medical science. Although it is impossible to keep up-to-date in the
moment of practice, we have provided categories and links, both here and throughout the text, along with brief explanations of
their relevance, to extend the usefulness of this handbook into practice. Some examples are provided:
• Resources available to members on the American Physical Therapy Association website (apta.org):
• Physical Therapy Outcomes Registry: h p://www.ptoutcomes.com/home.aspx
• PTNow: h ps://www.ptnow.org/Default.aspx
• Clinical Practice Guidelines, including:
• Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed
with Venous Thromboembolism: Evidence-Based Clinical Practice Guideline
h ps://www.ptnow.org/clinical-practice-guideline-detail/role-of-physical-therapists-in-
management-of-indiv
• Early Rehabilitation for Patients in the Intensive Care Unit (ICU)
h ps://www.ptnow.org/clinical-summaries-detail/early-rehabilitation-patients-in-
intensive-care-unit
• Clinical Summaries:
• Stroke h ps://www.ptnow.org/clinical-summaries-detail/stroke-2#ViewComplete
• Documents created by the Academy of Acute Care Physical Therapy and available for free on their website
(h ps://www.acutept.org/):
• Laboratory values interpretation resources: 2017 Update and Point-of-Care document:
h ps://www.acutept.org/store/ViewProduct.aspx?id=10758036
• Resources specific to entry-level education:
• Core Competencies for Entry-Level Practice in Acute Care Physical Therapy
• Core Competencies for Entry-Level Physical Therapy Assistants in the Acute Care Se ing
• Interprofessional Practice Competencies:
• Interprofessional Education Collaborative: Core Competencies for Interprofessional Collaborative Practice:
2016 Update: h ps://www.ipecollaborative.org/resources.html.
With this fifth edition, editors Jaime Paz and Michele West have recruited two talented associate editors, Kathryn Panasci and
Kristin Curry Greenwood, to help make the peer review process more robust as well as to provide a transition for future
editions. For both Jaime and Michele, this will signal our last edition as editors of the Acute Care Handbook. Since the first
publication in 1997, we have been thankful to be able to contribute to this area of clinical practice. Along with our new associate
editors, we acknowledge the work of past contributors, some who have stayed on for many or all editions, and we welcome the
new contributors that have joined the team. Many of the new and returning contributors are either faculty or clinicians in
highly specialized acute care centers. The overall combination of our contributors allows material to remain current with
literature while providing clinically relevant information.
This edition of the Acute Care Handbook for Physical Therapists has been revised and updated to serve its original purpose. All
chapters include updated literature, available at the time of revision, to assist with implementing evidence-based practice in
this se ing. Each chapter centers on either a major body system or health condition and includes:
• A review of body structure and function

• An overview of the medical-surgical evaluation of a patient admi ed to the hospital, including pertinent diagnostic
procedures and laboratory tests
14
• A review of health conditions that emphasizes information pertinent to physical therapy management
• Guidelines and considerations for physical therapy examination and intervention
Clinical Tips appear throughout each chapter. These helpful hints are intended to maximize safety, quality, and efficiency of
care. As an essential member of the health care team, the physical therapist is often expected to understand hospital protocol,
safety, medical-surgical “lingo,” and the many aspects of patient care from the emergency room se ing to the ICU to the
general ward. These Clinical Tips are suggestions from the editors and contributors that, from clinical experience, have proved
to be beneficial in acclimating therapists to the acute care se ing. With advances in literature pertaining to acute care, more of
these tips have become validated and thus are referenced accordingly in this new edition.
It is important to remember that all information presented in this book is intended to serve as a guide to stimulate
independent critical thinking within the scope of practice of physical therapy and the spectrum of medical-surgical techniques
and trends. To implement evidence-based practice, this reference should serve as one of the many resources involved with
clinical decision making. As health care continues to evolve, clinicians will need to adapt information to the best of their ability.
Developing and maintaining a rapport with the medical-surgical team is essential to facilitate high-quality and safe patient
care. We believe the new edition of the Acute Care Handbook for Physical Therapists can enhance the content knowledge in the
acute care environment by providing valuable information to help interpret medical record reviews, prepare for physical
therapy examination and intervention, assist in sound clinical decision making, and support patient and interprofessional
interaction.
J.C.P.
M.P.W.
K.P.
K.C.G
15
Acknowledgments
We all offer sincere gratitude to the following people:
• Lauren Willis and Elsevier for their ongoing investment and belief in working toward a fifth edition of this book.
• Maria Broeker for her professional guidance, support, and immense patience with all of our questions during the entire
revision process.
• Jodi Willard for her welcoming assistance, flexibility, and open communication in the production process.
• The contributors—both past and present. This textbook obviously doesn’t exist without all of the hard work and
dedication each of you has put toward this project. Both physical therapists and patients have benefited from your
expertise.
• The many patients and students who continually challenge yet enrich our lives, both professionally and personally.
Personal thanks from Jaime to:
• Tallie, for continually reminding me what’s important in life.

• Michele West, for all of your collaboration throughout the years and editions.
• Kristin Curry Greenwood and Kate Panasci, for your willingness to step up as Associate Editors—the future is in good
hands with you both.
• The PT faculty at Walsh University, who continue to be great teammates.
• The dedicated clinicians, faculty, and researchers who have helped advance the body of knowledge in this practice area.
• My faith and church community, who support me in ways I didn’t know was possible.
Personal thanks from Michele to:
• Jaime Paz, for sharing your knowledge with me in the RICU at the beginning of my career and for the countless hours
of work spanning decades as co-authors and editors.
• Kate Panasci and Kristin Curry Greenwood, for your hard work and care of the fifth and future editions of the Acute
Care Handbook for Physical Therapists.
• Paula and Mike Panik, the best parents a daughter could hope for, thank you for…everything.
• Marie Panik, a wonderful sister, for all of your quiet yet strong support.
• Isabelle and Genevieve West, my beautiful daughters, for your love and faith in me, and for sharing the computer
nicely.
• Tracee Murphy, my lifelong friend, who has cheered me on for all five editions of this book.
• My friends, both old and new, for your encouragement throughout the publishing process.
• My co-workers and patients, who inspire me to become a be er clinician.
Personal thanks from Kate to:
• Jaime Paz, for the opportunity to be involved with this project following a random email from a former student who
tracked you down.
• Jaime Paz, Michele West, and Kristin Curry Greenwood, for all of your comradery, insight, and support throughout the
process.
• My Texas Tech University Health Sciences Center colleagues and friends, for se ing the bar high and providing a fun
environment in which to strive to exceed it.
• My University Medical Center colleagues and friends, for all that you have taught me and for keeping me on as part of
the team.
• My past, present, and future patients and students—you are why I love what I do every day. Thank you.
Personal thanks from Kristin to:
• My husband and children, Alex and Hannah, who motivate me to achieve my personal and professional goals each day.
• Jaime Paz, for your education first as a professor and now as a mentor in this Associate Editor role—thank you for your
belief and trust in my ability to add to this great text.
• To Michele West, for your guidance and oversight with Chapter 18.
• To Kate Panasci, for your collaboration and teamwork tackling this new challenge together, which has made this a more
rewarding experience.
• To the contributors whose chapters I edited, who share their knowledge and patience with me in this new Associate
Editor role.
• To the community of Northeastern University, who first educated me, then embraced me as faculty and department
chair, and who continue to move the profession of physical therapy forward every day.
16
• To the Elsevier staff, who provided guidance every step of the way.
• To the Academy of Acute Care Physical Therapy, for their agreement to allow links to their materials and for their
ongoing dedication to the advancement of knowledge and the advancement of acute care physical therapy.
17
PA R T 1
Introduction
OUTLINE
Chapter 1. The Acute Care Se ing
Chapter 2. The Medical Record
18
CHAPTER 1
The Acute Care Se ing

Kathryn Panasci a
Introduction
Safe Caregiver and Patient Environment
Fall Risk
Use of Restraints
Medication Reconciliation
Latex Allergy
Effects of Prolonged Bed Rest
Intensive Care Unit Setting
Common Patient and Family Responses to the Intensive Care Unit
Critical Illness Myopathy, Polyneuropathy, and Polyneuromyopathy
Sleep Pattern Disturbance
Substance Use and Withdrawal
Severity of Injury and Illness
End-of-Life Considerations
Resuscitation Status
Withholding and Withdrawing Medical Therapies
Palliative and Hospice Care
Advance Directives
Coma, Vegetative State, and Brain Death
CHAPTER OBJECTIVES
The objectives of this chapter are the following:

1. Review basic safety guidelines and principles for the physical therapist and patient in the hospital setting
2. Identify the multisystem effects of prolonged bed rest that can occur with hospitalization and the relevant physical therapy
considerations
3. Describe the unique characteristics of, and patient response(s) to, the intensive care unit
4. Review alcohol use disorders and alcohol withdrawal syndrome
5. Identify assessment scales used for defining severity of injury or illness
6. Discuss end-of-life considerations and palliative care concepts
Introduction
The physical therapist must have an appreciation for the distinct aspects of inpatient acute care. This chapter provides a brief
overview of the acute care environment, including safety and the use of physical restraints; the effects of prolonged bed rest;
end-of-life considerations; and some of the unique circumstances, conditions, and patient responses encountered in the hospital
se ing.
The acute care or hospital se ing is a unique environment with protocols and standards of practice and safety that may not
be applicable to other areas of health care delivery, such as an outpatient clinic or school system. Hospitals are designed to
accommodate a wide variety of routine, urgent, or emergent patient care needs. The clinical expertise of the staff and the
medical-surgical equipment used in the acute care se ing (see Chapter 18) reflect these needs. The nature of the hospital se ing
is to provide 24-hour care; thus the patient, family, and caregivers are faced with the physical, psychological, and emotional
sequelae of illness and hospitalization. This can include the response(s) to a change in daily routine, lack of privacy and
independence, or a potential lifestyle change, medical crisis, critical illness, or long-term illness.
19
Safe Caregiver and Patient Environment
Patient safety is a top priority. Physical therapists should strive to keep the patient safe at all times, comply with hospital
initiatives that maximize patient safety, and understand patient safety goals established by their accrediting agency. Basic
guidelines for providing a safe caregiver and patient environment include the following:
• Reduce the risk of health care–associated infections by always following Standard Precautions, including compliance
with hand hygiene guidelines. 1 Refer to Table 13.3 for a summary of precautions to prevent infection, including
standard, airborne, droplet, and contact precautions.
• Be familiar with the different alarm systems, including how and when to use equipment such as code call bu ons, staff
assist bu ons, and bathroom call lights.
• Know the facility’s policy regarding accidental exposure to chemicals, wastes, or sharps, as well as emergency
procedures for evacuation, fire, internal situation, and natural disaster. Know how to contact the employee health
service and hospital security.
• Confirm that you are with the correct patient before initiating physical therapy intervention, according to the facility’s
policy. Most acute care hospitals require two patient identifiers (by patient report or on an identification bracelet), such
as name and hospital identification (ID) number, telephone number, or another patient-specific number. A patient’s
room number or physical location may not be used as an identifier. 1 Notify the nurse if a patient is missing an ID
bracelet.
• Elevate the height of the bed as needed to ensure your use of proper body mechanics when performing a bed-level
intervention (e.g., stretching, therapeutic exercise, bed mobility training, or wound care).
• Leave the bed or chair (e.g., stretcher chair, recliner chair) in the lowest position with wheels locked when the patient
will be seated at the edge of the surface, exiting or entering the surface, and after physical therapy intervention is
complete. Leave the top bed rails up for all patients.
• Use only equipment (e.g., assistive devices, recliner chairs, wheelchairs) that is in good working condition. If equipment
is unsafe, then label it as such and contact the appropriate personnel to repair or discard it.
• Keep the patient’s room as neat and clu er free as possible to minimize the risk of trips and falls. Pick up objects that
have fallen on the floor. Secure electrical cords (e.g., for the bed or intravenous pumps) out of the way. Keep small
equipment used for physical therapy intervention (e.g., cuff weights, Theraband) in a drawer or closet. Do not block the
doorway or pathway to and from the patient’s bed.
• Store assistive devices at the perimeter of the room when not in use. However, when patients are allowed to ambulate
independently with an assistive device, the device should be in safe proximity to the patient.
• Provide enough light for the patient to move about the room or clearly see reading materials.
• Reorient a patient who is confused or disoriented. Often, patients who are confused are assigned rooms closer to the
nursing station.
• Always leave the patient with the call bell or other communication devices within close reach. These include eyeglasses
and hearing aids. Be sure to inquire if the patient will be using the room telephone, personal cellular phone, or both,
and be sure it is within reach.
• Provide recommendations to nursing staff for the use of bathroom equipment (e.g., tub bench, bedside commode, or
raised toilet seat) if the patient has functional limitations that may pose a safety risk.
• Dispose of soiled linens, dressings, sharps, and garbage according to the policies of the facility.
Fall Risk
A fall is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower
level.” 2 A fall by this definition applies to the conscious or unconscious patient. For hospitalized patients, a fall is one of the
most common adverse events and accounts for increased hospital personnel needs, length of stay, cost, and morbidity and
mortality, especially among older adults. 3 Fall prevention during hospitalization includes a fall risk assessment performed on
admission by nursing staff. Further prevention of falls involves a multitude of strategies and safety initiatives, including
personal alarms, proper footwear, medication review, frequent toileting, adequate room lighting, and routine mobilization. The
standardized fall risk assessment performed on admission varies by facility; however, common risk factors considered include
prior falls, advanced age, medications, visual acuity, muscle strength, functional abilities (e.g., gait, balance, and mobility), and
any medical conditions associated with falls (e.g., neurologic, orthopedic, or cognitive impairments; postural hypotension). 4
On the basis of the fall risk score and the subsequent designation of increased fall risk, a patient is identified as such
(depending on hospital policy) by a specialized wristband and/or colored hospital gown, on a sign at the doorway to the room,
and in the medical record.
Use of Restraints
The use of a restraint may be indicated for the patient who is at risk of self-harm or harm to others, including health care
providers, facility staff, and other patients. 5 A restraint is defined as “any manual method, physical or mechanical device,
material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely; or
a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of
movement and is not a standard treatment or dosage for the patient’s condition.” 5 It should also be noted that “a restraint does
not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other
methods that involve the physical holding of a patient for the purpose of conducing routine physical examinations or tests, or
to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical
harm.” 5
The most common types of physical restraints in the acute care se ing are wrist or ankle restraints, mi restraints, vest
restraints, or an enclosure bed. Side rails on a bed are considered a restraint when they are elevated with the intent of
20
preventing the patient from exiting the bed, such as when all four rails are raised. 5 The use of restraints requires an order from
a licensed independent practitioner (LIP) that must be updated approximately every 24 hours. At that time, an LIP must assess
the patient in person before documenting a new order to continue restraint use. 5 A patient on restraints must be monitored
frequently, either continuously or at predetermined time increments, depending on the type of restraint used and in
accordance with facility policy and procedure and state law. 5
Although restraints are used with the intent to prevent injury, morbidity and mortality risks are associated with physical
restraint use. Most notably, the presence of the restraint and the resultant limitation of patient mobility can increase agitation.
New-onset pressure ulcers or alterations in skin integrity, urinary incontinence, constipation, and physical deconditioning can
also occur. Musculoskeletal or nerve injury from prolonged positioning or from pushing or pulling on the restraint or
strangulation/asphyxiation from the restraint as a result of entrapment can occur if the patient is not monitored closely. Many
clinical guidelines and hospital care plans and policies reflect the trend of minimizing restraint use and deferring to
alternatives, including regular assessment for personal needs such as scheduled toileting, food and fluids, sleep, and walking;
bed and chair alarms to alert staff when a patient has moved from a bed or chair unassisted; diversions such as reading
material, activity kits, or movement activities; recruitment of help from family or other patient care companions; relaxation
techniques; alternative methods of camouflaging or securing medical devices, lines, or wires; and adequate pain management.
6,7
Use of restraints should be a last-resort option after all alternatives have been explored.
General guidelines most applicable to the physical therapist for the use of restraints include the following:
• Use a slipknot rather than a square knot to secure a restraint if the restraint does not have a quick-release connector.
This ensures that the restraint can be untied rapidly in an emergency.
• Do not secure the restraint to a movable object (e.g., the bed rail), to an object that the patient is not lying or si ing on,
or within reach of the patient so that he or she could easily remove it. If using restraints in the hospital bed, they should
be secured to a part of the bed that will move with the patient if the head or feet se ings are adjusted for positioning.
• Ensure the restraint is secure but not too tight. Place two fingers between the restraint and the patient to be sure
circulation and skin integrity are not impaired.
• Always replace the restraint after a physical therapy session.
• Be sure the patient does not trip on the ties or “tails” of the restraint during functional mobility training.
• Consult with the health care team to determine whether a patient needs to have continued restraint use, especially if
you feel the patient’s behavior and safety have improved.
• Remember that the side effects of a chemical restraint may make a patient drowsy or alter his or her mental status; thus
participation in a physical therapy session may be limited.
Medication Reconciliation
Medication reconciliation is the process of comparing a list of the medication(s) a patient is taking with that ordered on
admission, on transfer between areas of the hospital, and on discharge for the purpose of ensuring an up-to-date medication
list. 8 Medication reconciliation is an important safety initiative in hospitals to prevent medication errors, such as inadvertent
omission or duplication of a medication, incorrect dosing, and drug interactions. This also ensures that all health care providers
can access the same complete medication list. 8
Latex Allergy
Latex allergy is a hypersensitivity to the proteins in natural rubber latex. If the reaction is immediate, then it is immunoglobulin
E (IgE) mediated, with systemic symptoms resulting from histamine release. 9 If the reaction is delayed, typically 48 to 96 hours
after exposure, it is T-cell mediated, with symptoms localized at the area of contact and related to the processing chemicals
used in the production of natural rubber latex. 9 Signs and symptoms of an allergic reaction to latex range from mild to severe
and may include hives, edema, contact dermatitis, rhinitis, headache, eye or throat irritation, abdominal cramping, respiratory
difficulty (e.g., wheezing or shortness of breath), chest tightness, and possible anaphylaxis. 9-11
Natural rubber latex is used in a multitude of products and equipment found in the acute care se ing. This commonly
includes gloves, stethoscopes, blood pressure cuffs, airway and intravenous tubing, adhesive tape, dressings, electrode pads,
catheters, tubes, therapy/resistance bands, and hand grips on assistive devices. Many hospitals have minimized or eliminated
latex products, replacing them with nonlatex or low-protein, powder-free latex products for the benefit of both the patient and
health care provider. 9-12 Effective January 1, 2018, the U.S. Food and Drug Administration officially banned powdered
surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove because of
the “unreasonable and substantial risk of illness or injury… including health care worker and patient sensitization to natural
rubber latex.” 13
Less than 1% of the general population has a sensitization to latex; health care workers have a greater incidence, between 8%
and 17%. 9,10 Persons with spina bifida, congenital or urogenital defects, multiple childhood surgeries or medical treatments,
occupational exposures to latex, or certain food allergies are at increased risk for latex allergy. 9,10 An association exists between
latex sensitivity and food allergies, in which a person can have a cross-reactive allergy to a food (often a fruit) that is linked
allergenically to natural rubber latex. This cross-reactivity is known as latex–food syndrome or latex–fruit allergy, and the
foods most strongly associated with allergic reactions include banana, kiwi, avocado, and chestnuts. Apples, carrots, celery,
papaya, potato, tomato, and melons have a moderate association with latex allergies. 9-11,14 Although not all people with latex
sensitivity will also be allergic to these foods, awareness of the possibility is important.
If a patient has an allergy or hypersensitivity to latex, then it is documented in the medical record and at the patient’s
bedside. Hospitals will provide a special latex-free kit or cart, which consists of latex-free products for use during patient care.
Health care providers may be at risk for developing a latex allergy because of their increased exposure to latex in the work
se ing. The latex allergy protein reaches the skin during exposure to the latex product. This risk is increased with powdered
glove use because the skin is exposed to increased amounts of the latex protein through the powder. Aerosolized latex protein
21
powder can also become an irritant to the airways and eyes, resulting in the respiratory and ocular symptoms noted
previously. 12 If you suspect a latex hypersensitivity or allergy, seek assistance from the employee health office or a primary
care physician.
Effects of Prolonged Bed Rest

The effects of short-term (days to weeks) or long-term (weeks to months) bed rest can be deleterious and affect every organ
system in the body. For the purposes of this discussion, the term bed rest includes immobilization, disuse, and prolonged
recumbency. The physical therapist must recognize that a patient in the acute care se ing is likely to have an alteration in
physiology (e.g., a traumatic or medical-surgical disease or dysfunction) superimposed on bed rest, a second abnormal
physiologic state. 15 Many patients on bed rest have been in the intensive care unit (ICU) for extended periods of time with
multisystem organ failure or hemodynamic instability, requiring sedation and mechanical ventilation. Other clinical situations
classically associated with long-term bed rest include severe burns; multiple trauma injuries; spinal cord injury; acute
respiratory distress syndrome (ARDS); or nonhealing, full-thickness wounds (e.g., stage 4 pressure injuries) of the lower
extremity or sacrum.
Physiologic consequences of bed rest include, but are not limited to, fluid volume redistribution, altered distribution of body
weight and pressure, muscular inactivity, and aerobic deconditioning. 16 The degree of impairment in each system is directly
related to the severity of illness or injury and the duration of bed rest. It has been noted that the cardiovascular and pulmonary
systems deteriorate more rapidly and recover more slowly compared with the musculoskeletal system. This is seen more
dramatically in the older adult population. 16 It is beyond the scope of this book to discuss in detail the physiologic and cellular
mechanisms of the sequelae of prolonged bed rest; however, Table 1.1 lists the major systemic changes.
• Monitor vital signs carefully, especially during mobilization at the edge and out of the bed.
• Progressively raise the head of the bed before or during a physical therapy session to allow blood pressure to regulate.
Stretcher chairs (chairs that can position the patient from supine to different degrees of reclined or upright si ing) are
also useful if orthostatic hypotension or activity intolerance prevents standing activity or if the patient may need to
quickly return to the supine position.
• If hypotension persists after more than a few treatment sessions, consider the use of lower extremity antiembolism
stockings, with or without elastic wrapping, when performing initial static si ing activities to minimize pooling of
blood in the lower extremities. An abdominal binder may also be helpful to increase return from the abdominal
vasculature to the central system.
• Time frames for physical therapy goals will likely be longer for the patient who has been on prolonged bed rest.
• Supplement formal physical therapy sessions with independent or family-assisted therapeutic exercise for a more
timely recovery.
• Be aware of the psychosocial aspects of prolonged bed rest. Sensory deprivation, boredom, depression, and a sense of
loss of control can occur. 17 These feelings may manifest as emotional lability or irritability, and caregivers may
incorrectly perceive the patient to be uncooperative.
• As much as the patient wants to be off bed rest, he or she will likely be fearful the first time out of bed, especially if the
patient has insight into his or her muscular weakness and impaired aerobic capacity. Additional assistance (e.g.,
rehabilitation technicians, other licensed rehabilitation clinicians, nurses) may be necessary the first time up to the edge
or out of the bed to ensure patient safety and medical stability.
• After treatment, leave necessities and commonly used items (e.g., call bell, television control, telephone, reading
material, beverages, food, tissues) within reach to minimize feelings of confinement.
• Be sure to use bed or chair alarm systems or restraints, if ordered, to minimize the risk of falls.
Intensive Care Unit Setting

As its name suggests, the ICU is a place of intensive medical-surgical care for patients who require continuous monitoring,
usually in conjunction with certain therapies or medical interventions, such as vasoactive medications, sedation, circulatory
assist devices, and mechanical ventilation. ICUs are often named according to the specialized care that they provide, for
example, coronary care unit (CCU) or surgical ICU (SICU). The patient in the ICU requires a high level of care; thus the nurse-
to-patient ratio is 1:1 or 1:2.
Common Patient and Family Responses to the Intensive Care Unit

Admission to the ICU has an effect on both the patient and family members that extends beyond the question of recovery from
injury or illness. Patients in the ICU experience psychological, behavioral, and social challenges as a result of the stress
experienced during their time in critical care. 18,19 The stress experienced by the patient and family members is not a ributed to
poor coping mechanisms or underlying psychological disorders; rather, they become overwhelmed by the number and severity
of environmental and psychological stressors experienced in these care units. 19 Patients are faced with environmental stressors
such as physical restrictions, sleep deprivation, unfamiliar medical equipment, crowding, excessive lighting, odors, noises, and
touch associated with procedures. 18,19 Psychological stressors can include diminished dignity and self-esteem, powerlessness,
loss of autonomy, vulnerability, boredom, pain, fear, anxiety, isolation, uncertainty about the future, and spiritual distress. 18,19
The patient’s family can also become overwhelmed by the ICU se ing. Family members may experience fear, shock, anxiety,
stress, helplessness, anger, and denial. 20,21 Like the patient, the family may be overwhelmed by the stimuli and technology of
the ICU, in addition to the stress of a loved one’s critical or life-threatening illness. Holistic, patient-centered care must include
family members and their well-being in addition to the primary concern, which is care of the patient. Health care providers
22
should make every effort to recognize the needs of the family and identify and implement strategies to meet those needs to the
best of their ability. 21
TABLE 1.1
Systemic Effects of Prolonged Bed Rest

Body System Effects
Cardiac Increased heart rate at rest and with submaximal exercise
Decreased stroke volume, VO2max, left ventricular volume, and cardiac output
Myocardial thinning
Orthostatic hypotension
Hematologic Decreased total blood volume, red blood cell mass, and plasma volume
Increased hematocrit
Venous stasis, hypercoagulability, and blood vessel damage (Virchow triad), causing increased risk of venous thromboembolism
Respiratory Decreased lung volumes and capacities, especially FRC, FVC, and FEV1
Decreased mucociliary clearance
Increased risk of pneumonia, atelectasis, and pulmonary embolism
Decreased arterial oxygen saturation
Gastrointestinal Decreased appetite, fluid intake, bowel motility, and gastric bicarbonate secretion
Gastroesophageal reflux
Difficulty swallowing
Genitourinary Increased mineral excretion, kidney stones, difficulty voiding, and urinary retention
Increased risk of urinary tract infection
Endocrine Altered temperature and sweating responses, circadian rhythm, regulation of hormones, increased cortisol secretion, and glucose
intolerance
Decreased overall metabolism
Musculoskeletal Muscle: increased muscle weakness (especially in antigravity muscles), atrophy, decreased muscle endurance, risk of contracture,
weakened myotendinous junction, and altered muscle excitation
Bone: disuse osteoporosis
Joints: degeneration of cartilage, synovial atrophy, and ankylosis
Neurologic Sensory and social deprivation
Decreased dopamine, noradrenaline, and serotonin levels
Depression, restlessness, insomnia
Decreased balance, coordination, and visual acuity
Increased risk of compression neuropathy
Reduced pain threshold
Integumentary Increased risk of pressure injury formation
Immune system Increased risk of reactivation of latent viruses
Reduced immune response and immunity
Psychological Impaired self-worth and self-esteem
Increased risk of delirium, depression, and pos raumatic stress syndrome
Body Increased sodium, calcium, potassium, phosphorus, sulfur, and nitrogen loss
composition Increased body fat and decreased lean body mass
Fluid shift from the legs to the abdomen/thorax/head, diuresis, natriuresis, dehydration
FEV 1 , Forced expiratory volume in 1 second; FRC, functional residual capacity; FVC, forced vital capacity; VO2max, maximum oxygen update.
Data from Dean E, Butcher S. Mobilization and exercise: physiological basis for assessment, evaluation, and training. In: Frownfelter D,
Dean E, ed. Cardiovascular and Pulmonary Physical Therapy Evidence to Practice. 5th ed. St. Louis, Elsevier; 2012; Bartels M, Prince DZ.
Acute medical conditions. In: Cifu DX, ed. Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier; 2016; Knight J,
Nigam Y, Jones A. Effects of bed rest 1: cardiovascular, respiratory, and haemotological systems. Effects of bed rest 2: Gastrointestinal,
endocrine, renal, reproductive, and nervous systems. Effects of bed rest 3: musculoskeletal and immune systems, skin and self-
perception (website): h p://www.nursingtimes.net. Accessed August 27, 2018.
An acute state of delirium, often termed ICU delirium, ICU syndrome, or ICU psychosis, is a state of delirium that can occur
during the stay in the ICU. Delirium is a “disturbance in consciousness with ina ention accompanied by a change in cognition
or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time.” 22 The exact
pathophysiology of ICU delirium is unknown, but research has demonstrated that ICU patients may have 10 or more identified
risk factors and are at a much higher risk for the development of delirium compared with other populations. 22 A strong
association has been found between delirium and variables such as mechanical ventilation, emergency surgery, polytrauma,
organ failure, hypertension, metabolic acidosis, coma, history of dementia, and advanced age. 23 Other possible risk factors
include hypoxemia, use of certain benzodiazepine and narcotic medications, infection, immobilization, and pain. 22 ICU
delirium is associated with increased time on mechanical ventilation, long-term cognitive impairments, extended length of ICU
and hospital stay, increased cost, and higher rates of mortality. 22
ICU delirium may present as hyperactive (characterized by agitation and restlessness), hypoactive (characterized by
withdrawal and flat affect or by decreased responsiveness), or mixed (a fluctuation between the two). 24 Most patients will
experience delirium of either mixed or hypoactive nature. Purely hyperactive delirium is reported in less than 5% of ICU
patients. 24 It is important to recognize the distinction between ICU delirium and dementia. ICU delirium has a sudden onset of
new cognitive and behavior changes a ributed to the current medical situation. Dementia has a more gradual onset and would
not be triggered by an ICU admission. 24
Current practice guidelines recommend that adult ICU patients be regularly assessed for ICU delirium. Accepted assessment
tools are the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening
Checklist (ICDSC). 22 These tools are most appropriately used in tandem with an additional validated assessment of
consciousness, one example being the Richmond Agitation-Sedation Scale (RASS). 24,25 Both the CAM-ICU and the ICDSC have
been validated for use with verbal patients as well as those on mechanical ventilation. 25
23
Management strategies for delirium include both pharmacologic and nonpharmacologic interventions. Pharmacologic
strategies focus on a thorough review of current medications to identify and eliminate or decrease those that may be causing or
exacerbating the delirium (e.g., sedatives, benzodiazepines, analgesics, and/or anticholinergic medications). 22 Current
literature is limited with regard to the use of specific medications for the treatment of ICU delirium. 22 Nonpharmacologic
interventions include minimizing all risk factors; repeated reorientation and cognitive stimulation throughout the day;
maximization of the normal sleep pa ern; hydration; pain management; early mobility; removal of lines, wires, and restraints,
when appropriate; use of eyeglasses and hearing aids; and minimizing noxious noises or environmental stimuli. 22
The transfer of a patient from the ICU to a general floor unit can be a stressful and anxiety-provoking event for the patient
and family. Referred to as relocation stress syndrome, the patient and family may voice concerns about leaving staff members
whom they have come to recognize and know by name; they may have to learn to trust new staff, or fear that the level of care
may be inferior to that in the ICU. 20 To minimize this anxiety, the physical therapist may continue to treat the patient (if
staffing allows), gradually transition the care to another therapist, or assure the patient and family that the general goals of
physical therapy will remain unchanged.
Critical Illness Myopathy, Polyneuropathy, and Polyneuromyopathy

Together, critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy
(CIPNM, a combination of both CIM and CIP) are the leading causes of ICU-related neuromuscular weakness, often resulting
in difficulty or failure to successfully wean from mechanical ventilation. 26 These processes involve sensorimotor axons and
skeletal muscles, resulting in significant limb and respiratory muscle weakness. Diagnosis is ideally confirmed through
electrodiagnostic studies (e.g., nerve conduction and electromyography [EMG]); however, the feasibility of these studies can be
limited in the ICU se ing. Therefore muscle biopsy and examination of the phrenic nerve and diaphragm can also be helpful
diagnostic tools. 26,27 Differential diagnoses may include Guillain-Barré syndrome, amyotrophic lateral sclerosis, sarcoidosis,
myasthenia gravis, rhabdomyolysis, medication toxicity, metabolic neuropathies, ongoing neuromuscular blockage, and
muscular dystrophy. 26,27 Diagnosis is often first considered when the patient demonstrates failure to wean from mechanical
ventilation. Because of the complex medical state of the patient (e.g., sedation, drug-induced paralysis, and possible
encephalopathy), it is often difficult to determine the actual time of onset. 26 CIM and CIPNM are more often reported, with
occurrence rates between 25% and 83%. The likelihood of pure CIP is still being debated among experts. 26 The patient’s
underlying medical condition is a large factor in determining the development and severity of CIM, CIP, and CIPNM. Acute
respiratory distress, respiratory failure, mechanical ventilation, trauma, use of vasopressors, intravenous steroid use, sepsis,
systemic inflammatory response syndrome, multiple organ failure, inadequate blood glucose control, renal replacement
therapy, and prolonged immobility have all been identified as possible variables that increase the risk of developing CIM, CIP,
or CIPNM. 26,27
CIM presents as flaccid, symmetric weakness that is more proximal than distal and includes respiratory muscles. Atrophy
will be noted as the illness progresses. Sensation is preserved, but reflexes are generally decreased or absent. 26-28
Electrodiagnostic testing demonstrates reduced amplitude of motor action potentials and an inability to excite muscle tissue
despite direct stimulation. Sensory findings are near or at normal. Muscle biopsy will reveal evidence of denervation and
reinnervation with fiber-type grouping and atrophy. 26
CIP presents as flaccid, bilateral, distal extremity weakness, sensory loss, and paresthesia. Although deep tendon reflexes
usually remain intact initially, they will likely decrease over time. 26-28 The lower extremities are generally affected more
compared with the upper extremities, and findings may not be symmetric in nature. 26 Nerve conduction studies demonstrate
decreased amplitude of both sensory and motor action potentials without conduction velocity impairment. 26,28 Nerve biopsy
reveals widespread motor and sensory nerve degeneration. 26
CIPNM is a condition with overlap of both CIM and CIP such that electrodiagnostic and clinical features of both will be
noted. 26
Initial symptoms of CIM, CIP, and CIPNM are generally noted within 2 weeks of admission to the ICU but have been
reported as soon as 72 hours. 26 Medical management includes supportive and symptomatic care, treatment of the causative
factor, and physical therapy. No proven cure exists; however, an intensive insulin regimen is the only medical intervention
with notable clinical benefit. 26
Sleep Pattern Disturbance

The biological need for sleep is well understood. Ill and injured individuals require increased amounts of sleep over the healthy
population to facilitate recovery. However, adequate sleep, in both quantity and quality, can be difficult to obtain in the acute
care se ing. 29-32 Sleep disturbance is defined as “insufficient duration or stages of sleep that results in discomfort and interferes
with quality of life.” 30 Inadequate or disrupted sleep can result in impaired health and well-being (e.g., immune, metabolic,
cardiorespiratory, and neurologic system dysfunction); delayed healing or recovery; decreased energy levels; alterations in
cognition, mental status, and mood; and increased stress, anxiety, and pain. 29,31,32 The defining characteristics of sleep
disturbance are difficulty falling or remaining asleep with or without fatigue on awakening, drowsiness during the day,
decreased overall functioning, inability to concentrate, and mood alterations. 33
In the acute care se ing, sleep disturbance may be related to both environmental and nonenvironmental causes.
Environmental concerns include frequent awakenings associated with a medical procedure or the need for nursing intervention
(e.g., monitoring of vital signs); elevated noise levels, light exposure (e.g., disruptive light at night and inadequate light during
the day), and the challenges of sleeping in an unfamiliar environment. 29,31,32 Nonenvironmental causes of disrupted sleep may
include the severity of the current disease or illness, pain, medications, and certain medical interventions (e.g., ventilation,
dialysis, urinary catheters, external orthopedic hardware or devices, and other lines and wires). 29,31,32 Sleep disturbance is often
24
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be brought from a vessel which had recently reached the coast. A
great event was the arrival of three vessels with two hundred
Spaniards, eighty horses, and a full complement of arms,
ammunition, and other effects, partly bought and partly enlisted by
the agents whom Cortés had despatched to the Islands during the
previous autumn. Among the new-comers were Julian de Alderete of
Tordesillas, appointed royal treasurer for New Spain, and the
Franciscan Pedro Melgarejo de Urrea of Seville, bearing a supply of
papal indulgences for the men who had been engaged in the
crusade. That the soldiers were conscious of frequent transgressions
may be judged from the suggestive and not wholly reverential
observation of Bernal Diaz, that “after patching their defects the friar
returned to Spain within a few months, a rich man.”[1075]
Cortés was cheered by offers of submission and alliance, owing
partly to the good offices of Tezcucans and other allies. Some came
from places quite distant, such as Nautla and Tuzapan, on the coast
north of Villa Rica, laden as usual with presents.[1076] Another
pleasing evidence of still more devoted loyalty came not long after
from the south, from the country of the valiant Chinantecs, of the
long pikes. During the great uprising, when Spaniards in small or
straggling parties had everywhere been slaughtered, this people
faithfully protected the two soldiers who happened to be with them,
and were in return aided by their prowess and advice to achieve
victories over adjoining tribes. One of these men, Captain Hernando
de Barrientos, sent two natives in April with a letter to his
countrymen imparting the assurance that Chinantla and its six sub-
towns were loyal.[1077]
The recent successes and the arrival of the two hundred men
induced Cortés once more to propose peace to Quauhtemotzin. To
this end, during passion week, he bade some of the captured nobles
proceed to Mexico with a letter as a symbol of their commission, and
impress upon their master the superiority in arms and skill of the
Spanish forces, their constant and large reinforcements, and their
unvarying success in the field. They must point out the generous and
humane treatment of the provinces which had submitted, and assure
the Aztec leaders that equal forgiveness would be accorded them.
Refusal to return to their allegiance would lead to the destruction of
themselves and their city. Only two of the captives ventured to
accept the commission, for according to Aztec articles of war any
noble who returned to his country after having been captured by an
enemy was doomed to decapitation unless he had performed some
extraordinary deed.[1078]
No answer came from Mexico, and it was afterward learned that
the messengers had suffered death. The Aztec ruler had not even
given a thought to peace. He was watching his opponents, prepared
to take advantage of any neglect or relaxation in their effort. No
sooner had Sandoval been induced by peaceful appearances to
retire from Chalco than Aztec forces again prepared to invade the
province. The Chalcans had due warning, and close upon the heels
of Sandoval came two messengers lamenting louder than ever, and
exhibiting a painting wherein were named the many towns whose
forces were coming upon them, fully fifty thousand strong. These
constant menaces and movements were exasperating, and Cortés
resolved personally to inflict a lesson which might be lasting. At the
same time he proposed to complete his reconnoissance of the lake
region and encourage his troops with spoils from hostile localities
whereon the Aztecs yet relied for support.[1079]
Cortés selected thirty horse, three hundred infantry, a number of
Tlascaltecs, and over twenty thousand Tezcucans, under Prince
Ixtlilxochitl, to which twice that number of other allies were added on
the way. A large proportion of archers and aquebusiers were taken,
together with Alvarado, Olid, Alderete, Melgarejo, and others, while
Sandoval was left in charge of Tezcuco, with instructions to watch
and promote the completion of the brigantines against which several
incendiary attempts had been made.
The expedition left Friday, the 5th of April, and passed through
Chalco, Tlalmanalco, and Chimalhuacan,[1080] and crossing in a
south-westerly direction into the Totolapan province, they entered the
hills which form the southern border of the Mexican valley. By this
time the forces had assumed proportions hardly inferior to those of
the Iztocan campaign, when over one hundred thousand moved
against the foe. Highly picturesque was the spectacle of this army, its
naked hordes of warriors relieved by plumage and glittering iztli
points which rose above the broad line of gaudy shields; its white
adventurers in mail of cotton and metal, surmounted by bright
helmets, and armed knights on proudly stepping steeds: picturesque
in particular as it wound in almost endless line along the rounded
slopes of the cliffs, or climbed in clearly defined file across the hill-
tops, only to descend again into gulches gloomy as their own sinister
purpose.
Alarmed by the invasion, the inhabitants had abandoned their
valley homes, and had sought refuge on the summits, whence they
hurled missiles at the passing lines. Little attention was paid these
irregular bands, composed as they were to a great extent of women
and children. On entering the Tlayacapan Valley, however, and
observing on the craggy sides of an almost perpendicular isolated
rock, perched there like an eagle’s nest, a place of refuge peopled
with more pretentious opposers, in a fit of insensate folly Cortés
ordered the place to be assailed. He seemed to think the honor of
the army demanded it, and was ready to stake the lives of valuable
men on its destruction.
Orders were given to attack from three several sides, the
steepest being assigned to Alférez Corral, a brave and spirited
leader. Verdugo and Villafuerte were given another side, and Ircio
and Monjaraz the third. Each party consisted of about threescore
men, and included archers and arquebusiers. At a given signal all
rushed forward to the ascent. Soon they were on hands and knees,
crawling over projections and pulling themselves up by means of
shrubs. All the while stones and darts rattled on helmet and
breastplate; and huge rocks came rolling down upon them. In vain
they sought shelter in crevices and under crags; they must face the
storm. Bernal Diaz followed Corral, and after receiving many a hard
knock they gained what was called two turns of the rock. There they
paused and looked around, wondering at their success thus far.
Supporting himself against a small tree, his face bathed in blood, his
banner rent, Corral said, “Señor Diaz, it is useless to advance
farther; not a man will survive.” Then they shouted a warning to
Pedro Barba, at the head of his archers, not to climb farther. “The
order is to advance!” was the reply. The next moment Barba was
wounded by a stone, and a soldier at his side was killed. Cortés then
sounded the recall, but not until eight brave men had laid down their
lives, victims of their commander’s puerility, and of the rest most of
them returned wounded.[1081]
The recall was likewise prompted by the approach of a
considerable force in the valley. This the cavalry charged and quickly
routed, following in close pursuit, though the broken ground soon
enabled the fugitives to gain shelter. During this ride some of the
horsemen came, a league beyond, to another hill fortress, strong in
its natural features, and held by a large force. Near by were some
springs. The need of water was pressing, which afforded a plausible
excuse for abandoning the scaling of Tlayacapan, and the whole
force was moved to the springs. Early next morning Cortés
examined the approaches to the new stronghold. It extended over
three hills, the central one exceedingly steep and held by the largest
force; the others easier of ascent, though higher, and occupied by
smaller numbers. In reconnoitring, Cortés advanced toward the
centre. This movement led the occupants of the other hills to infer an
attack on the central height, and they began to abandon their
positions with a view to reënforce the threatened point. Observing
this, Cortés ordered Barba to occupy the most commanding
elevation with some fifty arquebusiers and archers, while he himself
continued to scale the centre as a feint, for there was little hope of
capturing a point so steep and strongly held. The stones and darts
rained here as previously, and man after man was struck down,
some bleeding freely from the wounds sustained.[1082]
Meanwhile Barba’s sharp-shooters had made so effective a use
of their weapons that within half an hour the volleys from the fortress
ceased, and the women began to wave their robes in token of truce,
shouting their submission. Cortés graciously met the advances, and
extended full pardon. He also prevailed on the chiefs to induce the
Tlayacapans to submit. On the extensive surface of the rock were
collected all the inhabitants of the neighborhood, with their effects,
which Cortés ordered not to be touched.[1083]
The army remained encamped for two days to refresh
themselves after their arduous march, and after sending the
wounded to Tezcuco, Cortés proceeded to Huastepec. The report of
the clemency extended to preceding settlements had a reassuring
effect on this town, whose cacique came forth to welcome them, and
tender his palace for their entertainment. This was situated in a
garden, celebrated throughout New Spain for its beauty and extent,
and the immense variety of its plants, collected partly for scientific
purposes. A river with tributary canals flowed through its grounds,
which extended over a circuit of nearly two leagues, murmuring its
melody in unison with winged songsters hidden in arbors or playing
between bush and hedge, mingling their bright color with the green
expanse. Adjacent were steep rocks, on whose smooth surface were
sculptured the portraits of noted warriors, statesmen, and orators,
with hieroglyphic inscriptions of their fame. It was a paradise formed
equally for student and idler, and to the weary soldiers no spot could
perhaps have proven so grateful. Cortés certainly grows ecstatic in
describing it, declaring it “the largest, most beautiful, and freshest
garden ever seen.”[1084] Tempting as was the retreat, Cortés tore
himself from it the following day, and proceeded in a south-westerly
direction to Yauhtepec. Although many warriors were gathered there,
they fled on the approach of the Spaniards, and were chased, with
some slaughter, for about two leagues, into the town of Xiuhtepec.
[1085] The women and effects there found were appropriated as
spoils, and rendered agreeable the two days’ stay. The ruler failing to
appear, the place was fired, and terrified by this warning the lord of
Yauhtepec hastened to proffer submission.
After a day’s hard march the army came in sight of
Quauhnahuac,[1086] capital of the Tlahuicas. They were one of the
Nahuatlaca tribes, which according to tradition had entered the
Anáhuac country to supplant the Toltecs. Coming rather late, they
found their brethren already in possession of the lake region, and so
they crossed the range to seek a home on the headwaters of the
Zacatula, where soon a number of settlements rose round
Quauhnahuac. They afterward fell under the sway of the
Chichimecs, and finally the Aztecs took advantage of internal discord
to establish sovereignty,[1087] maintaining it by a garrison in the
capital. This was a natural stronghold, situated on a tongue of land
between two steep ravines over forty feet in depth, and through
which ran a little stream during the rainy season. It was further
protected by strong walls, particularly on the side where a strongly
guarded gate opened to a fine stretch of country. Two other
entrances faced the ravines, sometimes spanned by bridges, which
were now removed.
Situated at the gateway to the tropical southern valleys, between
which and the colder lake region interposed a range of mountains,
the spot stood as a new Eden in its manifold beauties. A sight even
of the pine-fringed mountains that rolled off toward the north, with
their green slopes shaded by oak and birch, and bathed in soft
though bracing airs, was refreshing to the indolent inhabitants of the
burning plain beyond. On the other hand the sturdy toilers of the
northern plateaux might in this sunny south seek relaxation in the
varied charms of a softer air balmy with the incense of a more
lustrous vegetation.[1088]
It was an opulent community that of Quauhnahuac, surrounded
as it was by endless resources and advantages, and the people
were in no mood tamely to yield their wealth to invaders. And in this
determination they were sustained by their lord, Yohuatzin,[1089] who
was not only a vassal but a relative of Quauhtemotzin. Confident in
the impregnable position of his city, in which supplies were ample, he
replied with volleys to the demands of the Spanish forces as they
appeared on the other side of the ravines. It seemed almost
impossible to effect a crossing and climb the steep wall of the ravine
to the city; nevertheless Cortés selected a position and began to
open fire so as to occupy the attention of the garrison and cover the
scaling parties.
While they were thus busied a brave Tlascaltec reconnoitred and
came to a point half a league beyond, where the ravine was steepest
and narrowed to an abyss. On the two sides grew two large trees,
which inclined toward each other, with branches intertwined, forming
a sort of natural bridge, though by no means secure. He called the
attention of his party to this and led the way across, followed by
several Spaniards. The natives, who were more accustomed to this
kind of tactics, found comparatively little difficulty in swinging
themselves across; but to the soldiers it was far from easy, and three
of them, overcome by dizziness or weight of armor, slipped and fell.
[1090]
The attention of the inhabitants being attracted elsewhere, a
number of the invaders had gained a secure foothold within the city
before they were observed. Even now a few resolute men might
have driven them back, but such were wanting, and the sudden
appearance of the dreaded white men, as if indeed they had
dropped into the stronghold from some cloud made radiant by the
sun whose reputed children they were, struck terror to the hearts of
the poor natives. All impotent and nerveless, they permitted the
daring strangers to lower the drawbridge, and turned to spread the
panic. Meanwhile the reports of a formidable army advancing from
the rear so wrought on the fears of the garrison that, when the
handful who had crossed on the bushy bridge fell on them, they
offered no resistance. This also allowed the scaling forces to pour in,
so that within a short time the siege was turned into a rout, wherein
the cavalry played a prominent part. The zeal of the allies was
already indicated by smoky columns in different parts of the city, and
the foot-soldiers hastened to share in the rich plunder and intercept
the women.
Most of the fugitives had gathered on an adjacent height, and
though no attempt was made that day to molest them, yet they
began to fear that men who could so readily capture one of the
strongest fortresses in the country, would find no difficulty in reaching
them anywhere; therefore, after listening to the advice of
messengers sent by Cortés, Yohuatzin concluded to surrender, and
presented himself on the following day with a large retinue and rich
presents. The Mexicans were as usual blamed for the opposition
offered. He would have submitted before, but thought it best to
expiate the fault of resistance by allowing the Spaniards to pursue,
so that after spending their fury they might be more ready to forgive.
[1091]
There was no time at present to extend the reconnoissance

farther in this direction, and after a brief rest Cortés turned northward
to the lakes. The route over the mountains proved far more difficult
than before, and after issuing from the pine forest the army entered a
desert country terminating in a three-league pass through the Ajuzco
Mountains. Here thirst became so intense that several natives
succumbed.[1092] This suffering was relieved in a hamlet not far from
the pass.
On the following day they passed through a fine and cultivated
country toward Xochilmilco, that is to say, Field of Flowers, aptly
named, for round almost every house, particularly on the outskirts,
was a flower-garden enclosed by canals. Many of them were of the
chinampa class, or floating gardens,[1093] the outgrowth of early
Aztec weakness, now forming a picturesque border to the lake
towns. Altogether the aspect was most pleasing, while the buildings
of the central parts were artistic and striking. Besides the strength
added by canals and moats, pile buildings were frequent, and
intrenchments had been thrown up and drawbridges raised to defend
the approach against any enemy of the Aztecs, for its loyalty to the
queen city was fully as great as that of Iztapalapan. It was the most
important place on the thickly settled fresh-water lake. Bishop
Garcés relates that angels were heard to sing praises in the Mexican
tongue when it was converted.[1094] The usual summons was issued
by the Spaniards, and no heed being given, they attacked in three
divisions by different approaches. The enemy fell back behind the
raised bridges and intrenchments, whence they kept up a steady
volley. The archers and arquebusiers replied briskly, and covered the
van as it plunged into not very deep water and waded across to
capture the fortifications. This effected, the foe was driven from one
retreat to another. Seeing how affairs went, they sought to parley, but
the pursuers paid no heed, regarding it as a trick to gain time for the
removal of their families and property. Within half an hour the greater
part of the city was won, and soldiers and allies were sacking as they
advanced. The foe rallied now and then to cover their retreat, and in
one instance managed to despatch two soldiers who had allowed
avarice to overcome prudence.
Not long after, a body of some ten thousand warriors, reënforced
by fugitives from the city, was seen advancing from the rear as if to
cut off retreat. They were already close at hand when first observed,
and without losing a moment Cortés charged them at the head of a
body of cavalry.[1095]
At first they boldly faced the animals, and fought so well as to
severely wound four, besides several riders; but the mounted body
kept breaking through their ranks and then turned to fall on the rear.
This movement proved decisive, and the enemy dispersed in flight,
the horsemen scattering in pursuit. Already weakened by the severe
march across the mountains, the horse of Cortés became quite
exhausted, and while its rider was striking right and left into a large
body of fugitives, it fell. No other horseman being near, the enemy
gathered courage and rushed upon the general, who had risen to his
feet and stood with sword in hand to defend himself. It was a critical
moment, and had not a brave Tlascaltec warrior come to his rescue
thus opportunely, the career of the Estremaduran would have ended
there; for he had already received a severe blow on the head and
was about to be dragged away when thus rescued. The general’s
body-guard then came up and cut in pieces his late stupid assailants
—stupid because they might so easily have killed him, and did not.
[1096]
The pursuit was not long maintained, tired as the horses were,
and remounting his steed Cortés led the way back to camp in the
square.
Late as it was he superintended the filling of all the channels
which broke the causeways, and the erection of defences, and
ordered the soldiers to put in order their arms and prepare arrows.
The forces were distributed at three points, and extra guards were
posted for the night, together with bodies of troops at probable
landing-points. These precautions were prompted chiefly by the
evident effort of the last body of the enemy to shut up the army
within the city, a movement which boded other attempts, as Cortés
rightly supposed.
When Quauhtemotzin heard that the Spaniards had marched
against Xochimilco he called a council to consider the course to
adopt, and the result was the despatch of reënforcements. Finding
that the city had so easily fallen, he became furious. The gods were
indignant at the outrages of the strangers. Arms must be employed
more manfully, and, these failing, the loyal ones must let their nails
grow, as the last means of protection. The first step should be the
recovery of Xochimilco. That very night two thousand canoes were
sent with some twelve thousand warriors, and a similar force by land,
all approaching stealthily, without music.[1097]
The rumor of a probable night attack kept the Spanish camp on
the alert, and advised of this, the enemy made no attack. At dawn
their canoes were already swarming round the city, the inmates
rending the air with loud and repeated shouts, and brandishing their
weapons, those of the chiefs being captured Spanish swords. “With
your own arms you shall be killed, and we will eat you!” they cried.
“We fear you not, for Montezuma is dead!” At the same time the land
forces were seen approaching, evidently to assist the fleet in
besieging the Spaniards within the city, which would give the
Mexicans greater advantage, as they had well learned during the
siege of Mexico. Cortés understood the manœuvre, and leaving the
greater part of the infantry and allies to guard the city, he sallied with
most of the horse, in three parties, a few of the infantry and several
hundred Tlascaltecs, breaking through the enemy’s ranks and
gaining the foot of a hill in their rear, the Tepechpan.
While the enemy were rallying, Cortés led the horse round to
their denser flank, and gave orders to the infantry to allure the
Mexicans by climbing the steepest part of the hill and pretending to
escape. This succeeded, and the next moment they were attacked in
several directions with such effect as to cause a panic and drive
them in flight toward a quarter where one division of horse had taken
a stand. Five hundred Mexicans covered the field and five leaders
were among the captured, while the Spanish loss was only one
soldier and a few allies, including three Tlascaltec chiefs, although a
number were wounded. During the pursuit the foremost division of
horse came upon a further Mexican reënforcement, estimated at ten
thousand, which rallied the fugitives and caused the pursuers to halt.
Soon, however, the remaining force came up, the charge was
continued, and the Mexicans routed.[1098]
Too tired for long pursuit, the Spaniards returned by ten o’clock
in the morning to Xochimilco, where their garrison had repulsed the
lake force. The fight had been fierce, and the soldiers had exhausted
all their ammunition, capturing in return two Spanish swords. These
victories brought little satisfaction, however, for the captives gave
information that the forces so far sent were but detachments of the
armies destined for Xochimilco, which must be recovered, and the
Spaniards driven forth, if it cost the lives of all the men in Mexico.
The Spaniards might defeat force after force, but even victory must
so weaken them that the Mexicans would finally triumph. This
seemed to be confirmed by the movements of the fleet, which,
though repulsed, was still hovering thereabout.
Cortés now gave orders to burn the city, as a warning to the
wilful inhabitants and preparatory to its evacuation. The soldiers,
who had been interrupted in their plundering the day before, obeyed
with alacrity. Xochimilco was a wealthy city, and not a Spaniard or
ally but obtained an abundance of robes, feathers, and other effects,
and even some gold, which helped to cheer those whom ordinary
merchandise and slaves did not satisfy. The enemy had been
watchful, however, and in their canoes they flitted round the city to
cut off stragglers. At one point quite a charge was made, wherein
several Spaniards were wounded and four carried off alive. This
event did more to cast a gloom over the army than many defeats, for
all knew the fate of prisoners.[1099]
After a stay of three days, all fraught with hard fighting, the army
filed out from Xochimilco, presenting the appearance of a dilapidated
caravan rather than of a reconnoitring and fighting expedition, so
much so that Cortés thought it necessary to remonstrate, but in vain.
The enemy hovered about like vultures, to harass them in what they
regarded as a retreat. The march was made in regular fighting order,
with cavalry distributed in three sections, in van, rear, and on flank.
In order to complete the reconnoissance, a north-westerly route was
taken to Coyuhuacan, the centre of a series of inner towns which lay
clustered within a radius of a league and a half, along the shores or
upon islands in the lake, all picturesque in their pyramidal temples
and their white walls, which gleamed amidst blooming orchards and
shady groves. Coyuhuacan itself was a beautiful town, and Cortés
felt so captivated with it that he afterward made it for some time his
favorite residence.[1100] It had been evacuated, but toward and
beyond Mexico the lake teemed with canoes, while in every direction
spread one continuous extent of farms and hamlets, connected by
causeways and roads with busy traffic. To Alderete and friar
Melgarejo this was a novel scene, and they could not refrain from
expressing their admiration at the enterprise and prowess of Cortés
and his followers in undertaking so vast a conquest. God’s aid alone
could have enabled them to succeed as they had done.[1101]
The army remained here over the following day, chiefly to
examine the place as intended head-quarters of a besieging force. It
was found satisfactory; and while arrows were prepared and the
wounded tended, the general advanced along the causeway leading
to Mexico and expended his remaining ammunition in the useless
capture of the temple fortress of Xoloc,[1102] during which a number
of soldiers were wounded, though the enemy suffered considerably.
After offering to heaven the fiery sacrifice of pagan temple, the army
proceeded through Tlacopan without halting, for they had no
ammunition, and this place had been examined on the previous
expedition. This unexpected haste encouraged the Mexicans to
come forth in great numbers and attack the baggage train and rear.
Owing to the level nature of the ground the cavalry found no difficulty
in repelling them, yet they caused more trouble, and succeeded
even in carrying off two of the favorite equerries[1103] of Cortés. He
was deeply grieved at the loss, and partly with a view to avenge
them, partly to inflict a lesson which should save the army from such
annoyance, he formed an ambuscade beside the road with twenty
horse. Seeing the other ten horses engaged as formerly in covering
the rear, the Mexicans continued their pursuit. At a favorable
moment the hidden horsemen appeared, and soon over a hundred
of the flower of the Mexicans lay dead upon the ground,[1104] their
rich panoplies, dresses, and arms offering a pleasing addition to the
already heavy plunder. Freed from further molestation, the army
proceeded through Azcapuzalco and Tenayocan to Quauhtitlan, all
deserted. Here the army clustered round camp fires of green wood,
wet from a recent shower and supperless. Next morning they
followed the route already pursued during the flight from Mexico,
round Zumpango Lake through Citlaltepec, and thence through
Acolman to Tezcuco.[1105]
A mass of booty and slaves being now at hand, a general
distribution was ordered, the second in Tezcuco. Again, says Bernal
Diaz, Cortés disregarded his promises and secured not only for
himself the objectionable fifth, but allowed his favorites to carry off
the prettiest women before they were brought forward at auction.
Many who remembered the former tricks hid their women and said
they had escaped, or they declared them free servants from allied
tribes; while a few managed to obtain a private branding, paying the
fifth required. A large proportion of the soldiers were so heavily in
debt for stores and fifths that their booty left them no surplus.[1106]
While the reconnoitring expeditions had on the whole been
fraught with pecuniary benefit and glory, they had nevertheless
served to open the eyes of many to the difficulty of the great
purpose, the capture of Mexico. This was particularly the case with
the Velazquez party, whose adhesion before the Tepeaca campaign
had been compulsory, and after it mercenary in its motives. Every
obstacle to them appeared terrible, magnified through constant fear
of the dreaded stone of sacrifice, on which so many comrades had
already been laid. And this they were encountering for what? the
advancement of an envied usurper and a pecuniary reward far
beneath their expectations. The failure at Iztapalapan, the repeated
inroads of the Mexicans, unabashed by constant repulses, and the
hardships of the campaigns, particularly the last, all tended to
support their arguments against Cortés’ plans as chimerical,
involving long delays, constant toil, and waste of life, and with poor
recompense save for Cortés and his favorites.
Presently the affair assumed the color of conspiracy, headed by
Antonio de Villafañe, a common soldier from Zamora, who is claimed
by Herrera to have had the active or passive sympathy of some
three hundred malcontents, nearly one third of the army. The
professed object was to secure a pliable leader who would consult
the wishes of the soldiers, even those desirous of returning. Such a
man, and withal of great influence and valor, was Verdugo, the
brother-in-law of the all-powerful patron Velazquez, and him the
conspirators chose as the new captain-general, unknown to himself,
since he might prove too honorable to engage in plots against the
commander. As a reward for his own efforts Villafañe claimed the
position of alguacil mayor, while other friends and influential men of
Narvaez were assured of the remaining offices, from alcalde mayor
and maestre de campo downward, now held by the retainers of
Cortés, as well as a share in the arms and other effects of the
doomed number.[1107] It was arranged that when Cortés was seated
at table with his intimate friends, as Alvarado, Sandoval, Olid, and
Tápia, a letter was to be handed him, as if coming from his father,
and while he was reading, the conspirators should fall on and stab
him and his supporters, since all must be removed who might prove
troublesome. The new officers were thereupon to be proclaimed,
together with the liberal plan agreed on, by which it was hoped to
allure even the friends of Cortés.
There were too many in the secret, however, and Cortés was a
man of magnetic influence. At the eleventh hour, two days after the
return from Xochimilco, says Diaz, an accomplice, struck with
compunction, rushed distractedly to the feet of Cortés and implored
pardon for having even dared to listen to the vile machinations. He
thereupon revealed the plot and stated that Villafañe carried the
names and details on a list in his breast-pocket. Cortés quietly
summoned his captains. He represented the need for a “remedy,
since, besides the scandal, it was evident that all the Spaniards must
perish if once they turned one against the other; and to this end not
only declared foes but allies would join.”[1108]
Attended by Sandoval and others, Cortés hastened to the house
of the accused and found several persons assembled. Some were
secured as they sought escape. Villafañe found time to take a paper
from his breast and tear it in pieces, but Cortés gathered and
arranged them,[1109] and was grieved to read the names of quite a
number of promising persons whom he had honored and regarded
as friends. Villafañe confessed the details of the plot, which had
been forming since the Tepeaca campaign. A court-martial was held,
presided over by Cortés himself, and there being no doubt of his
guilt, the accused was condemned to death and promptly hanged
from the window of his dwelling.[1110]
Cortés had probably no doubt regarding the guilt of the persons
named on the list, but the prosecution of so many notable men might
not be prudent, and would only widen the breach between himself
and the malcontents and gain them sympathy. The day following the
execution the general called a meeting. Many were the consciences
that pricked their possessors to trembling on that occasion. But the
sage Cortés preferred the traitors should risk their necks in winning
for him Mexico, rather than himself to break them with a rope.
Napoleon, who in national warfare could open with his sword the
veins of the people until there poured forth torrents of blood, shrank
in horror from blood shed in civil broils. It was policy with Cortés,
however. So, after finishing his narration of the conspiracy, he coolly
informed them that Villafañe had refused to reveal his accomplices,
and he could not therefore name the guilty. There were no doubt
men amongst them with real or fancied grievances which may have
induced them to harbor resentment; but let them frankly state their
wrongs and he would seek to right them. If he had erred, let the error
be named. The conclusion of the affair created general satisfaction.
Thankful for their escape, the guilty sought both by words and deeds
to prove their devotion, and although Cortés kept his eye upon them,
there was no indication that he suspected any. He rather sought to
win them back with favors.[1111] So impressed were his intimate
followers by the risk to which so valuable a life had been exposed
that they insisted on his accepting a body-guard of twelve select
men, under the command of Antonio de Quiñones, an hidalgo of
Zamora,[1112] who watched over him day and night.
FOOTNOTES
[1062] This is according to Cortés; others differ slightly, and Ixtlilxochitl increases
the Tezcucan force to 60,000. Hor. Crueldades, 13.
[1063] From tocatl and xal, spider and sand. Chimalpain, Hist. Conq., ii. 29. The
lake in which it lies is divided about the centre by an artificial causeway about one
league long, running from east to west, the southern water being now known as
San Cristóbal Ecatepec, from the town of that name, and the northern water as
Xaltocan or Tomanitla, San Cristóbal being also the general term for both waters.
[1064] See Native Races, ii. v.
[1065] Bachiller Alonso Perez, afterward fiscal of Mexico. Bernal Diaz, Hist.
Verdad., 135.
[1066] This incident was commemorated by some poetic follower in a ballad which
became a favorite with the conquerors:
En Tacuba está Cortés,

Con su esquadron esforçado,
Triste estaua, y muy penoso,
Triste, y con gran cuidado,
La vna mano en la mexilla,
Y la otra en el costado.
Which may be translated literally:
In Tacuba stands Cortés,

With his troopers strong and brave:
Sad he was and deeply grave;
Sad, and heavily oppressed.
With one hand his cheek he pressed;
Against his side, the other.
[1067] So runs Bernal Diaz’ account, which appears a little exaggerated, for
recently Cortés had shown the greatest caution, and would hardly have allowed
himself to be so readily trapped on so memorable a spot. Hist. Verdad., 126.
Cortés states that not a Spaniard was lost, though several Mexicans fell. Cartas,
187.
[1068] Herrera, dec. iii. lib. i. cap. vii.
[1069] They begged permission to return home, says Chimalpain, Hist. Conq., i.
31. Herrera relates that the efforts of Ojeda, by Cortés’ order, to take from the
Tlascaltecs the gold part of their booty so offended them that they began to desert.
The extortion was accordingly stopped, dec. iii. lib. i. cap. vii. Clavigero doubts the
story. Prescott regards the departure of the allies as distasteful to Cortés; but we
have seen that he did not care at present to encumber himself with too many
unruly auxiliaries to prey upon the peaceful provinces. The Tlascaltecs would
willingly have remained to share in raiding expeditions.
[1070] Including 8000 Tezcucans under Chichinquatzin. Ixtlilxochitl, Hor.

Crueldades, 15. On March 12th, says Vetancurt, Teatro Mex., pt. iii. 154.
[1071] Also known as Chimalhuacan-Chalco, to distinguish it from Chimalhuacan

on Tezcuco Lake.
[1072] Lorenzana inspected the position in later times. Cortés, Hist. N. Esp., 214.
[1073] ‘Que todos los que allí se hallaron afirman.’ Cortés, Cartas, 190. The
general lauds the achievement with rare fervor for him. Bernal Diaz sneers at the
river of blood story; but then he was not present to share the glory. The Roman
Mario was less dainty than these Spaniards under a similar circumstance,
commemorated by Plutarch; or as Floro more prosaically puts it: ‘Ut victor
Romanus de cruento flumine non plus aquæ biberit quam sanguinis barbarorum.’
Epitome, lib. iii. cap. iii.
[1074] Fifteen, says Bernal Diaz. Chimalpain, the Chalcan narrator, states that his
tribe lost 350 men, but killed 1500 foes, capturing the captain-general,
Chimalpopocatzin, a relative of the emperor, who now became a captain among
the Tezcucans, and was killed during the siege. Hist. Conq., ii. 34. Some of these
facts are evidently not very reliable. He also assumes that Sandoval lost eight
soldiers on again returning to Tezcuco.
[1075] The ‘comissario’ or clerk in charge of the bulls was Gerónimo Lopez,
afterward secretary at Mexico. Bernal Diaz, Hist. Verdad., 129. This author names
several of the arrivals, some of whom became captains of vessels. A number also
arrived during the following week, he adds, notably in Juan de Búrgos’ vessel,
which brought much material.
[1076] Gomara mentions also Maxcaltzinco as a distant place. Hist. Mex., 186.
[1077] The chiefs were awaiting orders to appear before Cortés. The general told
them to wait till tranquillity was more fully restored. The name of the other soldier
was Nicolás. Cortés, Cartas, 203-5. Herrera assumes that Barrientos arrived in
camp during the late Tepeaca campaign, dec. ii. lib. x. cap. xvii.
[1078] Of the rank and file none suffered penalty on returning, for captivity was
regarded as disgraceful only to a noble. Native Races, ii. 419.
[1079] Bernal Diaz states that the soldiers were tired of these repeated calls, many
being also on the sick-list, but Cortés had now a large fresh force only too eager
for a fray attended with spoliation.
[1080] According to a native painting the army entered here April 5th, which is a
day or two too early, and received a reënforcement of 20,000. See copy in
Carbajal Espinosa, Hist. Mex., ii. 523.
[1081] So says Bernal Diaz, Hist. Verdad., 130, who names four. Cortés allows
only two killed and twenty wounded; how many fatally so, he carefully omits to
mention. Cartas, 194.
[1082] Twenty fell, says Bernal Diaz. He speaks of two futile attempts on the
previous evening to scale the central hill. It seems unlikely for soldiers, tired by
repulse and march, to undertake so difficult a feat, and that at the least assailable
point.
[1083] Yet Bernal Diaz relates a story to show that the order was a mere pretence.
[1084] Cartas, 196; Torquemada, i. 536.
[1085] Some write Xilotepec. Bernal Diaz mentions Tepoxtlan, which may have
been visited by a detachment.
[1086] Place of the Eagle. Corrupted into the present Cuernavaca, which
singularly enough means cow’s horn.
[1087] See Native Races, v.
[1088] Cortés was so captivated by the alluring clime and scenery that he made
the town his favorite residence in later years. It was included in the domains
granted to him, and descended to his heirs. Madame Calderon speaks of his
ruined palace and church. Life in Mexico, ii. 50.
[1089] Ixtlilxochitl, Hist. Chich., 311. Brasseur de Bourbourg calls him Yaomahuitl.
[1090] ‘El vno se quebró la pierna ... y se me desvanecia la cabeça, y todavia

pasè yo, y otros veinte, ô trienta soldados.’ Bernal Diaz, Hist. Verdad., 132. Solis
misinterprets the passage, and gives this author credit for leading the party. Hist.
Mex., ii. 362. Vetancurt calls the district toward this spot Amanalco. Teatro Mex.,
pt. iii. 155.

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(eBook PDF) Acute Care Handbook for

Physical Therapists 5th Edition

Physiology of Chest Pain

Presentation of Chest Pain

Physical Therapy Considerations

Chapter 18. Medical-Surgical Equipment in the Acute Care Se ing

Appendix 18A:. Mechanical Ventilation

Appendix 18B:. Mechanical Circulatory Support Devices

Chapter 19. Pharmacologic Agents

Central Nervous System

Vascular System and Hematology

Chapter20. Anesthesia: Considerations for the Physical Therapist

Intraoperative Effects of Anesthesia

Postoperative Effects of Anesthesia

Physical Therapy Considerations

Chapter 21. Acute Pain Management

Methods of Airway Clearance

Pharmacologic Breathing Treatments

Creating an Airway Clearance Program

Chapter 23. Outcome Measures

Berg Balance Scale

Timed Up and Go Test

Dynamic Gait Index

Tinetti Performance-Oriented Mobility Assessment

Acute Care Index of Function

Function in Sitting Test

Six-Minute Walk Test

Self-Paced Walk Test

Activity Measure For Post–Acute Care “6 Clicks” Inpatient Short Form

Intensive Care Unit–Specific Outcome Measures

Confusion Assessment Method for the Intensive Care Unit

Intensive Care Unit Mobility Scale

Functional Status Score for the Intensive Care Unit

Perme Intensive Care Unit Mobility Score

Physical Function in Intensive Care Test—Scored

Appendix 23A: Functional Tests

Previous editions copyrighted 2014, 2009, 2002, 1997.

International Standard Book Number: 978-0-323-63919-4

Senior Content Strategist: Lauren Willis

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Sean M. Collins, PT, ScD

Adam B. Woolley, PharmD, MEd

Contributors to Previous Editions

Burns and Wounds

Burns and Wounds

Circulatory Assist Devices

David Nicoloro, PT, MS

To Nay and Tay—my gratitude for a life full of blessings.

To Tallie, Will, and Henry—my joy and my life.

For Isabelle and Genevieve, my sunshine!

For all the busy, hard-working, and devoted moms.

• A review of body structure and function

Personal thanks from Jaime to:

• Tallie, for continually reminding me what’s important in life.

Personal thanks from Michele to:

Personal thanks from Kate to:

Personal thanks from Kristin to:

Chapter 1. The Acute Care Se ing

Chapter 2. The Medical Record

The Acute Care Se ing

The objectives of this chapter are the following:

Effects of Prolonged Bed Rest