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2019v1.0
AACN
Core Curriculum
for Progressive
and Critical Care
Nursing
TONJA M. HARTJES, Editor
DNP, APRN, CNS, CCRN, CNEcl, FAANP
Owner, Nurse Practitioner and Consultant
Nursing Department
Coastal Consultants and Education LLC
St. Augustine Beach, Florida
Edition
8
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
AACN CORE CURRICULUM FOR PROGRESSIVE ISBN: 978-0-323-77808-4

AND CRITICAL CARE NURSING, EIGHTH EDITION
Copyright © 2023 by Elsevier, Inc. All rights reserved.
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Printed in India.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors
Bimbola Fola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC, FAANP
Associate Professor and Associate Dean for the MSN Program
Organizational Systems and Adult Health
University of Maryland, School of Nursing;
Acute Care Nurse Practitioner
Surgical Intensive Care Unit
University of Maryland Medical Center
Baltimore, Maryland
Chapter 2: Psychosocial Aspects of Critical Care
Jenny G. Alderden, PhD, APRN, CCRN, CCNS
Associate Professor
Boise State University, School of Nursing
Boise, Idaho
Chapter 16: Older Adult Patients
Angela Benefield, DNP, RN, AGCNS-BC, CCRN-CSC-CMC
Clinical Education Specialist/Clinical Consultant
Education and Professional Development
Independent Clinical Education Consultant
Temecula, California
Chapter 15: Bariatric Patients
Patricia A. Blissitt, PhD, ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BC
Neuroscience Clinical Nurse Specialist
Professional Development and Nursing Excellence
Harborview Medical Center;
Associate Professor, Clinical Faculty
University of Washington, School of Nursing;
Neuroscience Clinical Nurse Specialist
Clinical Education and Practice
Swedish Medical Center
Seattle, Washington
Chapter 5: Neurologic System
Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CEN
Advanced Practice Provider
Anesthesiology, Critical Care Medicine
University of Kentucky
Lexington, Kentucky
Adjunct Faculty
AGACNP Program
Georgetown University
Washington, District of Columbia
Chapter 4: Cardiovascular System
Chapter 6: Renal System
iii
iv Contributors
Nicole Brumfield, DNP, APRN, FNP-BC, AG-ACNP-BC

Anesthesiology, Critical Care Medicine
University of Kentucky
Lexington, Kentucky
Chapter 8: Hematologic and Immunologic Systems
Deborah Chapa, PhD, ACNP-BC, FAANP, ACHPN

Associate Professor, Nursing
Marshall University
Huntington, West Virginia
Chapter 2: Psychosocial Aspects of Critical Care
Catrina Cullen, RN, BSN, CCRN
University of Colorado, College of Nursing
Denver, Colorado
Chapter 19: Sedation
Anna Dermenchyan, MSN, RN, CCRN-K, CPHQ
Director of Quality
Department of Medicine
University of California – Los Angeles Health
Los Angeles, California
Chapter 1: Professional Caring and Ethical Practice
Andrea Efre, DNP, ARNP, ANP, FNP
Owner, Nurse Practitioner and Consultant
Healthcare Education Consultants
Tampa, Florida
Chapter 4: Cardiovascular System
Carrol Graves, MSN, RN, CCRN, CNL
Clinical Nurse Leader
Critical Care
North Florida/South Georgia Veterans Health System
Gainesville, Florida
Chapter 13: Hypothermia
Renee M. Holleran, FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN
(Retired), FAEN
Nurse Practitioner
Anesthesia Chronic Pain
Veterans Health Administration;
Former Manager of Adult Transport
Intermountain Life Flight
Intermountain Health Care
Salt Lake City, Utah;
Former Chief Flight Nurse
University Air Care
University Hospital
Cincinnati, Ohio;
Family Nurse Practitioner
Hope Free Clinic
Midvale, Utah
Chapter 11: Multisystem Trauma
Contributors v
Jennifer MacDermott, MS, RN, ACNS-BC, NP-C, CCRN

Nurse Practitioner
Hospital Medicine
St. Luke’s Health System
Boise, Idaho
Chapter 7: Endocrine System
Mary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K, FAAN, FNAP, FCNS
Professor
University of Colorado, College of Nursing
Aurora, Colorado;
Research Scientist
Denver Health
Denver, Colorado
Chapter 19: Sedation
Diane McLaughlin, DNP, AGACNP-BC, CCRN
Neurocritical Care
University of Florida Health - Jacksonville;
Critical Care Medicine
Mayo Clinic
Jacksonville, Florida;
Lecturer
Case Western Reserve University, School of Nursing
Cleveland, Ohio
Chapter 10: Sepsis and Septic Shock
Shana Metzger, MS, FNP-BC, AG-ACNP-BC
Adjunct Instructor
School of Nursing and Health Studies
Georgetown University
Washington, District of Columbia
Chapter 14: Toxin Exposure
Denise O’Brien, DNP, RN, ACNS-BC, CPAN, CAPA, FASPAN, FCNS, FAAN
Perianesthesia Clinical Nurse Specialist
Consultant
Self-Employed
Ypsilanti, Michigan
Chapter 22 Perioperative Care
Jan Odom-Forren, PhD, RN, CPAN, FASPAN, FAAN
Associate Professor
University of Kentucky, College of Nursing
Lexington, Kentucky;
Perianesthesia Nursing Consultant
Louisville, Kentucky
Chapter 22 Perioperative Care
vi Contributors
Patricia Radovich, PhD, CNS, FCCM

Director
Nursing Research
Loma Linda University Health Hospitals;
Assistant Professor
Loma Linda University, School of Nursing
Loma Linda, California;
Assistant Professor
California State University – Fullerton, School of Nursing
Fullerton, California;
Adjunct Professor
California State University - San Bernardino, School of Nursing
San Bernardino, California
Chapter 9: Gastrointestinal System
Tonya Sawyer-McGee, DNP, MBA, MSN, BSN, RN, ACNP-BC
Dean of Nursing
College of Nursing and Advanced Health Professions
The Chicago School of Professional Psychology
Richardson, Texas;
Adjunct Professor
Abilene Christian University, College of Nursing
Abilene, Texas
Chapter 20: Pain
Karah Cripe Sickler, RN, DNP, AG-ACNP-BC
Nurse Practitioner
Surgical Critical Care
University of Florida Health
Chapter 12: Burns
Daniel N. Storzer, DNP, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P, FCCP, FCCM
Pulmonary/Critical Care
Fox Valley Pulmonary Medicine
Neenah, Wisconsin;
Clinical Instructor
Acute Care Nurse Practitioner Program
Walden University;
Critical Care Paramedic
Waushara County EMS
Wautoma, Wisconsin
Chapter 3: Pulmonary System
Jennifer T.N. Treacy, MSN, APRN, FNP
Women, Infant, & Children Unit
Riverside Regional Medical Center
Newport News, Virginia
Chapter 17: High-Risk Obstetric Patients
Clareen Wiencek, PhD, RN, ACNP, ACHPN, FAAN
Associate Professor
Director of Advanced Practice
University of Virginia, School of Nursing
Charlottesville, Virginia
Chapter 21: Palliative and End-of-Life Care
Reviewers
Staccie Anne Allen, DNP, BSBA, APRN, AGACNP-BC, FNP-C, CFRN, EMT-P
Nurse Practitioner/Paramedic
ShandsCair Critical Care Transport Program
University of Florida Department of Emergency Medicine
University of Florida Health Shands Hospital
Angie Atwood, PhD, RN

Assistant Professor of Nursing
Campbellsville University
Campbellsville, Kentucky
Michele Beatty Bachmann, MSN, RN

Instructor
Department of Primary Care
Southern Illinois University – Edwardsville
Edwardsville, Illinois
Beverly L. Banks, BSN, MSN, RN

Senior Full-Time Faculty
Nursing
Alpena Community College
Alpena, Michigan
Debra J. Behr, DNP, RN, CCRN-K

Director of Professional Development and Magnet Program
Lutheran Medical Center
Wheat Ridge, Colorado
Collin Bowman-Woodall, MSN, RN

Assistant Professor
Samuel Merritt University, School of Nursing
San Mateo, California
Mary Ann “Cammy” Christie, APRN, MSN, CCRN, CMC-CSC, PCCN

Department of Critical Care Medicine and Surgery
University of Florida
vii
viii Reviewers
Judy E. Davidson, DNP, RN, MCCM, FAAN

Nurse Scientist
University of California – San Diego Health Sciences;
Scientist
Department of Psychiatry
University of California – San Diego, School of Medicine
La Jolla, California;
Associate Editor
Journal of Nursing Management
Tina Deatherage, DNP, RN, CCNS, CCRN, CNRN, NEA-BC

Hospital Accreditation Program Surveyor
The Joint Commission;
Adjunct Faculty, Nursing
Queens University
Charlotte, North Carolina
Christina Flint, MSN, MBA, RN

Assistant Professor
University of Indianapolis, School of Nursing
Indianapolis, Indiana
Matthew J. Fox, MSN, RN-BC

Assistant Professor
Nursing
Ohio University
Zanesville, Ohio
Keble Frazer, BSN, RN-BC, CCRN, PCCN

Registered Nurse
Medical and Surgical Intensive Care Units
Orange Regional Medical Center
Middletown, New York;
Montefiore Medical Center
Bronx, New York
Kelly A. Gaiolini, RN
Staff Nurse, Neuro/Surgical Intensive Care Unit
Lawnwood Regional Medical Center
Fort Pierce, Florida
Charles R. Gold, BSN, RN, CCRN

Registered Nurse
Neurosurgical Intensive Care Unit
Atrium Health’s Carolinas Medical Center
Reviewers ix
Ami Grek, DNP, APRN, ACNP-BC

Lead Advanced Practice Provider
Department of Critical Care
Associate Director
NP/PA Critical Care Fellowship Program
Assistant Professor of Medicine
Mayo Clinic School of Medicine
Jacksonville, Florida
Christopher Guelbert, DNP, RN, CCRN, CNML

Assistant Professor
Nursing
Barnes Jewish College
St. Louis, Missouri
Stephanie A. Gustman, BSN, MSN, DNP, RN

Associate Professor
Ferris State University
Big Rapids, Michigan
Christian Guzman, MS, CCRN, ACNPC-AG, APRN

Facility Director, Advanced Practice Providers
Intensivist Nurse Practitioner
Intensive Care Consortium
Jillian Hamel, MS, RN, ACNP-BC

Emergency Department Observation Unit
Providence Regional Medical Center
Everett, Washington
Sonya Renae Hardin, PhD, MBA/MHA, CCRN, ACNS-BC, NP-C, FAAN

Dean and Professor
University of Louisville, School of Nursing
Louisville, Kentucky
Kiersten Henry, DNP, ACNP-BC, CCNS, CCRN-CMC

Chief Advanced Practice Clinician
MedStar Montgomery Medical Center
Olney, Maryland
Cheryl Holsworth, MSA, RN, CBN, CMSRN

Senior Specialist for Bariatric Surgery
Sharp Memorial Hospital
San Diego, California
x Reviewers
Robert C. Ingram, BSN, MSN, MHA, DNPc, RN, CEN

Assistant Professor
Lourdes University, College of Nursing
Sylvania, Ohio
Tonia Kennedy, MSN, EdD, RN-BC, CCRN-K

Associate Professor
Liberty University, School of Nursing
Lynchburg, Virgina
Sara Knippa, MS, RN, CCRN, PCCN, ACCNS-AG

Clinical Nurse Specialist and Educator
Cardiac ICU
University of Colorado Hospital
CHealth
Aurora, Colorado
Marianna LeCron Presley, MSN, RN, CCRN

Critical Care Nurse
Medical Intensive Care
Atrium Health Pineville
KellyAnne Lee, MSN, MBA, RN, CCRN

Healthcare Consultant
Coasta Consulting Group, LLC
Mount Pleasant, South Carolina
Tanaya C. Lindstrom, MSN, RN, CCRN, CNL

Clinical Nurse Educator
Surgical/Medical Intensive Care Units
North Florida South Georgia Veterans Health System
Yvette Lowery, MSN/Ed, DNP, FNP-c, CCRN, CEN, PCCN

Family Nurse Practitioner
Emergency Department
Memorial Hospital
Karen A. Matos, MSN, RN, CCRN

Clinical Nurse Expert of Medical and Surgical Intensive Care Units and Telemetry
Nursing Education
Ralph H. Johnson Veterans Administration Hospital
Charleston, South Carolina
Paige McCraney, DNP, APRN

Adult Health Nurse Practitioner
Assistant Professor
University of North Georgia Department of Nursing
Dahlonega, Georgia
Reviewers xi
Denise M. McEnroe-Petitte, AS, BSN, MSN, PhD, RN

Associate Professor Nursing
Kent State University – Tuscarawas
New Philadelphia, Ohio
Katina M. Meyer, BSN, RN

Registered Nurse
Medical Intensive Care Unit
Stormont Vail Health
Topeka, Kansas
Samantha Palmer Noah, MSN, APRN, FNP-BC, AGACNP-BC

Nurse Practitioner
Flourish Health Network
DaiWai M. Olson, PhD, RN, CCRN, FNCS

Professor of Neurology & Neurotherapeutics
Professor of Neurosurgery
Distinguished Teaching Professor
University of Texas Southwestern Medical Center
Dallas, Texas
Sarah Peacock, DNP, APRN, ACNP-BC

Lead Advanced Provider
Department of Critical Care Medicine
Mayo Clinic
Deidra Pennington, MSN, RN

Assistant Professor
Nursing
Jefferson College of Health Sciences
Roanoke, Virginia
Ruthie Robinson, PhD, RN, CNS, FAEN, CEN, NEA-BC

Director, Graduate Nursing Studies
JoAnne Gay Dishman School of Nursing
Lamar University
Beaumont, Texas
Emily Rogers, DNP, AGACNP-BC, CCRN, APRN

Nurse Practitioner, Department of Critical Care
Mayo Clinic
xii Reviewers
Janet Czermak Russell, DNP, RN, APN-BC

Associate Professor of Nursing
Nursing/Biology
Essex County College
Newark, New Jersey
Peter D. Smith, BA, MSN, RN

Clinical Education Specialist
Nursing Education
Kindred Healthcare
St. Louis, Missouri
Diane Fuller Switzer, DNP, ARNP, FNP-BC, ENP-BC, ENP-C, CCRN, CEN, FAEN
Assistant Clinical Professor
Seattle University, College of Nursing
Seattle, Washington
Ashley N. Thompson, DNP, AGACNP-BC

Acute Care Nurse Practitioner, Assistant Professor
UF Health/University of Florida
Preface
Since the early 1970s, the American Association of Critical-Care Nurses (AACN) and its
AACN Core Curriculum have stood at the forefront of the continuing evolution of criti-
cal care nursing to better meet the highly specialized needs of the patients and families
they serve. The AACN Core Curriculum has now undergone eight editions, during which
time it has maintained its reputation as the source of all things critical care. Among sev-
eral steps we took to help prepare for this edition, AACN and I issued a reader survey and
gathered together a cross-section of expert clinicians for a focus group during the organi-
zation’s National Teaching Institute & Critical Care Exposition in 2019. Our goal was to
gather information to ensure that this newest edition kept pace with the expanding role
of nurses in the critical care profession. Participants confirmed the many ways the AACN
Core Curriculum is used: as a clinical reference in caring for progressive and critical care
patients, as a resource for CCRN certification exam preparation, for the creation of critical
care courses and curricula, as a cornerstone for new nurse orientation, and in the develop-
ment of competency content. Several nurses with whom we spoke stated that the AACN
Core Curriculum was their “critical care bible,” affirming that after all these years it is still an
actively sought-after resource within critical care nursing practice.
As we listened to readers and collected information from multiple sources, we confirmed
that the purpose of the AACN Core Curriculum remains, as it always has been, to articulate
the knowledge base that underlies progressive and critical care nursing practice. Each edi-
tion of this work attempts to redefine that knowledge base for nurses who practice in this
ever-expanding specialty area.
The eighth edition has been retitled AACN Core Curriculum for Progressive and Critical
Care Nursing. Critical care practice and nursing have evolved over the past decade. Acutely
ill patients are treated in many units of the hospital, from the Medical-Surgical departments
to progressive and intermediate care units and elsewhere. Patients requiring critical care
also are found outside the intensive care unit. Specialty nursing units have been created to
meet these evolving health care needs; critical care nurses and patients are found in car-
diac catheterization labs, emergency departments, and tele-ICUs. Sometimes they are even
found at home awaiting heart transplant with inotropic medications and a left ventricular
assist device. Changing the title of the text as we have done brings the resource more in
line with the varied settings in which we find critically ill patients, and it signals to readers
outside the traditional ICU that they are included in our base of readers.
Several similarities still exist between the seventh and eighth editions. The current edi-
tion continues to use the CCRN Examination blueprint and task statements as a starting
point for determining relevant content and its apportionment throughout the book. We
continue with the embellished outline format, and body systems are again used to divide
the major content areas into chapters. Subsections related to physiologic anatomy, patho-
physiology, and patient assessment; generalized patient care; and unique characteristics of
specific disorders also have been retained.
Readers can still find the AACN Synergy Model for Patient Care woven throughout this
edition. When it was developed in the late 1990s, the Synergy Model became the conceptual
framework for certified practice in critical care and has since been widely incorporated
across the discipline. Chapter 1 describes the model in detail, and each chapter includes in
the assessment section a reminder of the model’s prevalence. A key premise of the Synergy
Model is that patient characteristics drive the competencies that nurses need in order to
xiii
xiv Preface
provide holistic, healing care that achieves optimal patient outcomes. A knowledge base of
critical care nursing underlies clinical practice and reflects a foundational requirement for
the development of these nursing competencies.
AACN’s Competency Based Assessment (CBA) framework was incorporated as “lev-
eling” guidance using the Synergy Model for Patient Care and the expanded outline format
and embellishment items within the text. The terms novice, advanced beginner, proficient,
and expert were used to operationalize the nurse competency and leveling of content within
the AACN Core Curriculum.
The Novice or Advanced Beginner is encouraged to focus on the following content for
foundational knowledge:
Section 1: System Wide Elements
• Anatomy and Physiology Review
• Assessment
• Patient Care
• The new “Key Concept” highlight boxes have been expanded throughout the text,
and replace “Key Points” from the seventh edition
Proficient or Expert learners are encouraged to focus on the following content for
expert knowledge:
Section 2: Specific Patient Health Problems
• Health Problems
• Pathophysiology, Etiology, Signs and Symptoms, Diagnostic Findings, Management
of Patient Care, Complications, End Organ Diseases
• The new “Expert Tip” highlight boxes have been expanded throughout the text, and
replace the “Clinical Pearls” from the seventh edition
To keep pace with the expanding role of progressive and critical care nursing practice
and the evolving health care arena, the following items have been added or updated:
• Reorganization of content into four sections:
Part I: Foundations of Progressive and Critical Care Nursing
Part II: Critical Care of Patients with Issues Affecting Specific Body Systems
Part III: Critical Care of Patients with Multisystem Issues
Part IV: Critical Care of Patients with Special Needs
• Removal of all subchapters
• A new Perioperative Care chapter
• The text features improved navigation, format, and usability with a new, full-color, user-
friendly interior design that uses high-contrast text colors and a larger font.
• A Crosswalk was created at the beginning of each chapter that interfaces or maps foun-
dational nursing content within key educational and clinical documents including the
following:
• Quality and Safety in Nursing Education (QSEN) competencies
• National Patient Safety Goals
• American Nurses Association (ANA) Standards for Professional Nursing Practice
• American Association of Critical-Care Nurses (AACN) Standards for Progressive and
Critical Care Nursing Practice
• American Association of Critical-Care Nurses Healthy Work Environments
• Progressive and Critical Care Nursing Certification
• All chapters, tables, figures, boxes, and terminology are based on the most recently pub-
lished AACN/ANA Scope of Practice and Standards of Care.
• QSEN content has been incorporated within chapters of the text.
• The newest sepsis guidelines content has been added to Chapter 10.
Preface xv
• All references complement and reinforce current AACN and critical care standards and
guidelines of care.
• References and bibliographies for all chapters are now available online on the Evolve site
at http://evolve.elsevier.com/AACN/corecurriculum/.
• Each chapter was carefully reviewed by AACN clinical practice specialists as well as by
a nurse in current critical care practice. A clinical pharmacist also reviewed all medica-
tions for correct indication and dosages.
The contributors, reviewers, AACN clinical practice specialists, and I have worked tire-
lessly and made every attempt to provide the most current and relevant knowledge base
of information related to progressive and critical care nursing. I welcome your comments
about this edition and your suggestions for future editions of the AACN Core Curriculum.
Tonja M. Hartjes, DNP, APRN, CNS, CCRN, CNEcl, FAANP

Editor of the AACN Core Curriculum for Progressive
and Critical Care Nursing, 8th edition
tonjahartjes@gmail.com
Acknowledgments
This eighth edition of the AACN Core Curriculum is possible only because of the tireless
dedication and professionalism of many others, whose commitment to this project made
all the difference.
First, I would like to thank the devoted readers of the AACN Core Curriculum, who pro-
vided their time and thoughtful comments over the years regarding the use of the text and
suggestions for its evolution as nursing practice has evolved. Improvements in content and
design come in large part from their recommendations.
Many thanks to the contributors and reviewers whose enthusiasm, expertise, and expe-
riences have been shared with the readers. Their continued strength and resilience during
this especially important time (during the pandemic) is a testament to their commitment
to nursing. Development of this resource is made possible through the sustained efforts of
each contributor, whose insightful comments created an effective and useful clinical refer-
ence and CCRN review.
Sincere thanks and special recognition go to AACN’s publishing staff, Michael Muscat
and Katie Spiller, and the clinical practice specialists who provided endless time and dedi-
cation to me, to the contributors, to critical care nurses, and to the patients and families
we serve. Special thanks to Linda Bell, Julie Miller, Mary Stahl, Cindy Cain, and Marian
Altman for painstakingly reading through each chapter to offer suggestions.
I also wish to acknowledge those involved directly with the publication process. The
Elsevier staff provided considerable administrative support, and their organizational skills
and resources were a tremendous asset in the planning, preparation, and execution of this
text: Lee Henderson, Laura Selkirk, and Manchu Mohan.
Special thanks to my friend and mentor Suzanne Burns, without whose prior contribu-
tions to critical care nursing I would not be in this position. She has served as a role model
and mentored me throughout my career and the publishing process.
As always, I thank my family and friends who have been patient with my necessary
absences and whose love, support, and encouragement have inspired me throughout this
journey.
xvii
Contents
PART I Foundations of Progressive and Critical Care Nursing
Chapter 1 Professional Caring and Ethical Practice1
American Association of Critical-Care Nurses Mission, Vision, and Values
(AACN, 2020 a,b,c)
1
Mission1
Vision2
Values2
Synergy of Caring2
Key Responsibilities of Registered Nurses (American Nurses Association [ANA], 2020) 2
What Acute and Critical Care Nurses Do (AACN, 2019) 2
The Environment of Progressive and Critical Care Nurses (AACN, 2019) 2
The AACN Synergy Model for Patient Care 5
AACN Synergy Model for Patient Care (AACN, 2020a,b,c) 5

Origin of the Synergy Model 5
Purpose 5
Overview of the Synergy Model 5
Application of the Synergy Model 15
Family Presence: Visitation in the Adult ICU (AACN Practice Alert, 2016) 16
Healthy Work Environment Standards (AACN, 2016)17

General Legal Considerations Relevant to Critical Care Nursing Practice17
National Governing Bodies 17
State Nurse Practice Acts (Russell, 2017) 17
Scope of Practice 18
Standards of Care 18
Certification in a Specialty Area 19
Professional Liability 19
Documentation 22
Good Samaritan Laws 24
Ethical Clinical Practice24

Foundation of Ethical Nursing Practice 24
Emergence of Clinical Ethics 24
Standard Ethical Theory 25
Ethical Principles (ANA, 2015b) 25
Common Ethical Distinctions 26
Advance Care Planning 27
The Law in Clinical Ethics (Department of Health & Human Services, 2020) 29
Clinical Ethics Assessment 34
Nurse’s Role as Patient Advocate and Moral Agent 36
Chapter 2 Psychosocial Aspects of Critical Care38

Deborah Chapa, PhD, ACNP-BC, FAANP, ACHPN; Bimbola Fola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC, FAANP
Systemwide Elements38
Review of Psychosocial Concepts 38
Assessment 43
xix
xx Contents
Pain, Agitation, Delirium, Immobility and Sleep Disruption (PADIS) (Devlin et al., 2018) 44
Sleep Deprivation 46
ASD and PTSD 46
Delirium (Acute Confusional State) 48
Powerlessness 50
Anxiety 51
Depression 53
Substance Misuse, Dependence, and Withdrawal 55
Aggression and Violence 57
Suicide 59
Dying Process and Death 61
PART II ritical Care of Patients with Issues Affecting Specific Body

C
Systems
Chapter 3 Pulmonary System 63
Daniel N. Storzer, DNP, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P, FCCP, FCCM
Anatomy and Physiology Review 63
Assessment 85
Diagnostic Studies 105
Patient Care 109
Specific Patient Health Problems 136

Acute Respiratory Failure (ARF) 136
Chest Trauma 139
Acute Respiratory Distress Syndrome (ARDS) 139
Vaping 141
Transfusion-Related Lung Injury 142
Pulmonary Embolism 142
Chronic Obstructive Pulmonary Disease (COPD) 146
Asthma and Status Asthmaticus 150
Pneumonia 153
Ventilator-Associated Pneumonia and Event 157
Drowning 158
Pulmonary Problems in Surgical/Thoracic Surgery Patients 160
Air Leak Syndromes 162
Acute Pulmonary Inhalation Injuries 163
Neoplastic Lung Disease 163
Pulmonary Fibrosis 167
Obstructive Sleep Apnea 168
End-Stage Pulmonary Conditions: Lung Transplantation 169
Chapter 4 Cardiovascular System 176

Andrea Efre, DNP, ARNP, ANP, FNP and Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CEN
Assessment 190
Patient Care 232

Acute Coronary Syndrome 235
Acute Myocardial Infarction—ST-Segment Elevation Myocardial Infarction 235
Contents xxi
Non—ST Elevation Myocardial Infarction (See Acute Coronary Syndrome

(NSTEMI- Acute Coronary Syndrome and Unstable Angina)) 247
Chronic Stable Angina Pectoris 251
Coronary Artery Disease 253
Heart Failure257
Pericardial Disease266
Myocarditis271
Infective Endocarditis274
Cardiomyopathy280
Cardiac Rhythm Disorders286
Mitral Regurgitation 301
Mitral Stenosis 304
Aortic Regurgitation 307
Aortic Stenosis 310
Atrial Septal Defect 313
Ventricular Septal Defect 316
Patent Ductus Arteriosus 319
Coarctation of the Aorta 322
Hypertensive Crises 325
Aortic and Peripheral Arterial Disease 330
Shock 337
Mechanical Circulatory Support Devices 344
End-Stage Heart Disease: Cardiac Transplantation 350
Cardiac Trauma 353
Chapter 5 Neurologic System 354

Patricia A. Blissitt, PhD, ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BC
Assessment 390
Patient Care 408

Increased Intracranial Pressure or Intracranial Hypertension 417
Stroke 426
Brain Tumor 455
Spinal and Spinal Cord Tumors 459
Intracranial Infections 461
Neuromuscular/Autoimmune Disease 468
Seizure Disorders 476
Encephalopathy 483
Coma 486
Brain Death 487
Neurosurgical Procedures 488
Chapter 6 Renal System490

Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CEN
Anatomy and Physiology Review490
Assessment504
xxii Contents

Patient Care511
Specific Patient Health Problems520

Renal Trauma520
Acute Kidney Injury520
Chronic Kidney Disease534
Electrolyte Imbalances—Potassium Imbalance: Hyperkalemia540
Electrolyte Imbalances—Potassium Imbalance: Hypokalemia546
Electrolyte Imbalances—Sodium Imbalance: Hypernatremia547
Electrolyte Imbalances—Sodium Imbalance: Hyponatremia549
Electrolyte Imbalances—Calcium Imbalance: Hypercalcemia551
Electrolyte Imbalances—Calcium Imbalance: Hypocalcemia553
Electrolyte Imbalances—Phosphate Imbalance: Hyperphosphatemia554
Electrolyte Imbalances—Phosphate Imbalance: Hypophosphatemia556
Electrolyte Imbalances—Magnesium Imbalance: Hypermagnesemia557
Electrolyte Imbalances—Magnesium Imbalance: Hypomagnesemia558
Rhabdomyolysis559
End-Stage Renal Condition: Renal Transplant560
Chapter 7 Endocrine System564

Jennifer MacDermott, MS, RN, ACNS-BC, NP-C, CCRN
Hypothalamus565
Pituitary Gland (Also Called Hypophysis)565
Thyroid Gland568
Parathyroid Glands568
Adrenal Glands569
Pancreas570
Pineal Gland and Thymus Gland571
Gonadal Hormones (Testosterone, Estrogen, Progesterone)571
Assessment571
Diagnostic Studies574
Patient Care575
Altered Glucose Metabolism576
Altered Antidiuretic Hormone Production584
Altered Thyroid Hormone Production587
Acute Adrenal Insufficiency or Crisis591
Acute Hyperparathyroidism and Hypoparathyroidism592
Chapter 8 Hematologic and Immunologic Systems 593

Nicole Brumfield, DNP, APRN, FNP-BC, AG-ACNP-BC
Assessment of Hematologic and Immunologic Systems597
Diagnostic Studies599
Patient Care602

Contents xxiii
Thrombocytopenia604
Disseminated Intravascular Coagulation606
Medication-Induced Coagulopathy608
Thromboembolic Disorders611
Anemia613
Sickle Cell Anemia616
Neutropenia618
Acute Leukemia619
Malignant Pericardial Effusion 621
Hematopoietic Stem Cell Transplantation622
Organ Transplant Rejection624
Human Immunodeficiency Virus Infection626
Anaphylactic Reaction629
Chapter 9 Gastrointestinal System 631

Patricia Radovich, PhD, CNS, FCCM
Systemwide Elements 631
Accessory Organs of Digestion (Fig. 9.4)639
Patient Assessment644
Patient Care650

Abdominal Trauma652
Bowel Infarction (Obstruction, Perforation)652
Functional Gastrointestinal Disorders (Obstruction, Motility [Ileus, Diabetic Gastroparesis,
GERD, Inflammatory Bowel Syndrome])654
Gastrointestinal Infections (Clostridium Difficile)656
Abdominal Compartment Syndrome657
Acute Abdomen659
Acute Liver Failure661
Gastrointestinal Bleeding663
Gastrointestinal Bariatric Surgery667
Chronic Liver Failure: Decompensated Cirrhosis667
Carcinoma of the Gastrointestinal Tract672
Acute Pancreatitis675
Hepatitis678
End-Stage Gastrointestinal System Condition: Liver Transplantation682
Nutritional Support in the Critically Ill Patient683
PART III Critical Care of Patients with Multisystem Issues

Chapter 10 Sepsis and Septic Shock 686
Diane McLaughlin, DNP, AGACNP-BC, CCRN
Assessment 698
Patient Care700
xxiv Contents
Chapter 11 Multisystem Trauma 706

Renee M. Holleran, FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN (Retired), FAEN
Trauma Concepts and Physiology Review706
Assessment712
Patient Care718
Head and Spinal Trauma721
Thoracic Trauma: Pulmonary and Cardiac

734
Pulmonary Trauma734
Cardiac Trauma737
Abdominal Trauma741
Chapter 12 Burns745
Karah Cripe Sickler, RN, DNP, AG-ACNP-BC
Assessment754
Patient Care760
Chapter 13 Hypothermia764
Carrol Graves, MSN, RN, CCRN, CNL
Assessment 769
Patient Care 772
Chapter 14 Toxin Exposure 776

Shana Metzger, MS, FNP-BC, AG-ACNP-BC
Systemwide Elements 776
Anatomy and Physiologic Review 776
Assessment 787
Patient Care 790
Interventions for Ingestion of Toxic Substance (Fig. 14.1)792
General Management Strategies for Gastric Decontamination794
Treatment for Body Stuffing/Body Packing795
Additional Interventions for the Purposeful Ingestion795
Envenomation796
PART IV Critical Care of Patients With Special Needs

Chapter 15 Bariatric Patients799
Angela Benefield, DNP, RN, AGCNS-BC, CCRN-CSC-CMC
Assessment800
Patient Care804
Care of the Bariatric Surgery Patient 806
Related Bariatric Care Issues807

Contents xxv
Chapter 16 Older Adult Patients809

Jenny G. Alderden, PhD, APRN, CCRN, CCNS
Age-Related Biologic and Behavioral Differences809
Age-Related Changes in Medication Action and Clinical Implications809
The Four Ms of Age-Friendly Health Care814
Chapter 17 High-Risk Obstetric Patients820

Jennifer T.N. Treacy, MSN, APRN, FNP

Postpartum Hemorrhage823
Hypertensive Disorders of Pregnancy824
Hemolysis, Elevated Liver Enzymes, Low Platelet Count Syndrome830
Amniotic Fluid Embolism831
Acute Fatty Liver of Pregnancy832
Special Considerations833
Trauma833
Cardiopulmonary Concerns in Pregnant Patients835
Chapter 18 Patient Transport836

Renee M. Holleran, FNP-BC, PhD, CCRN (Alumnus), CEN, CFRN, CTRN (Retired), FAEN
Members of the Transport Team837
Indications for Transport837
Modes of Interfacility Transport838
Risks and Stresses of Transport839
Overriding Priorities in Patient Transport841
Preparation for Transport841
Patient Care During Transport844
Legal and Ethical Issues Related to Transport845
Chapter 19 Sedation846
Mary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K, FAAN, FNAP, FCNS and Catrina Cullen, RN, BSN, CCRN
Considerations Before Sedation846
Practice Considerations During Administration of Sedation848

Procedural Sedation and Analgesia for the Patient in High Acuity Settings855
xxvi Contents
Chapter 20 Pain860
Tonya Sawyer-McGee, BSN, MSN, MBA, RN, DNP, ACNP-BC
Background865
Assessment869
Patient Care873
Patient Education880
Specific Clinical Problems Related to Pain Therapy885
Chapter 21 Palliative and End-of-Life Care888

Clareen Wiencek, PhD, RN, ACNP, ACHPN, FAAN
Concept Review888
Assessment for Palliative Care, Hospice, or End-of-Life Care Services893
Patient Care893
Transitioning Goals of Care to End-of-Life (Box 21.3)895
Additional Considerations (See Ch. 2, Psychosocial Aspects of Critical Care)897
Chapter 22 Perioperative Care898

Jan Odom-Forren, PhD, RN, CPAN, FASPAN, FAAN and Denise O’Brien, DNP, RN, ACNS-BC, CPAN, CAPA, FASPAN, FCNS, FAAN
Assessment899
Patient Care901
Initial Arrival in Postanesthesia Care Unit or Intensive Care Unit914
Ongoing Postanesthesia Care—Emergence from Anesthesia914
Index923
PART I
Foundations of Progressive and Critical Care Nursing
CHAPTER
Professional Caring 1
and Ethical Practice
CROSSWALK
• Quality and Safety in Nursing Education (QSEN): Patient-centered care, Teamwork and
collaboration, Evidence-based practice, Quality improvement, Safety, Informatics
• National Patient Safety Goals: Identifies patients correctly, Improve staff communication, Use
medicines safely, Uses alarms safely, Prevents infection, Identify patient safety risks, Prevents
mistakes in surgery
• American Nurses Association (ANA) standards for Professional Nursing Practice:
Standard 1. Assessment, Standard 2. Diagnosis, Standard 3. Outcomes identification, Standard
4. Planning, Standard 5. Implementation, Standard 6. Evaluation, Standard 7. Ethics, Standard 8.
Culturally congruent practice, Standard 9. Communication, Standard 10. Collaboration, Standard
11. Leadership, Standard 12. Education, Standard 13. Evidence-based practice and research,
Standard 14. Quality of practice, Standard 15. Professional practice evaluation, Standard 16.
Resource utilization, Standard 17. Environmental health
• AACN Scope and Standards for Progressive and Critical Care Nursing Practice:
Standard 1. Quality of practice, Standard 2. Professional practice evaluation, Standard 3.
Education, Standard 4. Communication, Standard 5. Ethics, Standard 6. Collaboration, Standard
7. Evidence-based practice/research/clinical inquiry, Standard 8. Resource utilization, Standard 9.
Leadership, Standard 10. Environmental health
• AACN Standards for Establishing and Sustaining Healthy Work Environments (HWE):
Skilled communication, True collaboration, Effective decision-making, Appropriate staffing,
Meaningful recognition, Authentic leadership
• PCCN content: Professional Caring and Ethical Practice—All items
• CCRN content: Professional Caring and Ethical Practice—All items
AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES MISSION,

VISION, AND VALUES (AACN, 2020 a,b,c)
MISSION
1. Patients and their families rely on nurses at the most vulnerable times of their lives.
Acute and critical care nurses rely on AACN for expert knowledge and the influence
to fulfill their promise to patients and their families. AACN drives excellence
because nothing less is acceptable.
1
2 PART I Foundations of Progressive and Critical Care Nursing
VISION
1. AACN is dedicated to creating a healthcare system driven by the needs of patients
and families where acute and critical care nurses make their optimal contribution.
VALUES
1. As AACN works to promote its mission and vision, it is guided by values that are
rooted in, and arise from, the Association’s rich history, traditions, and culture.
AACN’s members, volunteers, and staff will honor the following:
a. Ethical accountability and integrity in relationships, organizational decisions, and
stewardship of resources.
b. Leadership to enable individuals to make their optimal contribution through lifelong
learning, critical thinking, and inquiry.
c. Excellence and innovation at every level of the organization to advance the
profession.
d. Collaboration to ensure quality patient- and family-focused care.
SYNERGY OF CARING
KEY RESPONSIBILITIES OF REGISTERED NURSES (AMERICAN NURSES
ASSOCIATION [ANA], 2020)
1. Perform physical examinations and health histories before making critical decisions.
2. Provide health promotion, counseling, and education.
3. Administer medications and other personalized interventions.
4. Coordinate care, in collaboration with a wide array of healthcare professionals.
WHAT ACUTE AND CRITICAL CARE NURSES DO (AACN, 2019)

1. Restore, support, promote, rehabilitate, or palliate to maintain the physiologic and
psychosocial stability of patients of all ages across the life span.
2. Synthesize and prioritize information to take immediate and decisive evidence-
based, patient-focused action using clinical judgment and clinical inquiry.
3. Anticipate and respond with confidence, and adapt to rapidly changing patient
conditions.
4. Respond to the unique needs of patients and families coping with unanticipated
illness or injury and treatment, and advocate for their choices in quality-of-life and
end-of-life decisions.
5. Establish and maintain a healthy work environment that is safe, respectful,
healing, and caring for nurses, peers, patients, families, and the interprofessional
team.
6. Demonstrate the financial contribution of nursing through appropriate resource
utilization, cost effectiveness, innovation, and efficiency, resulting in optimal safety
and quality outcomes.
7. Demonstrate the contribution of nursing to the quality and financial stability of the
facility through stewardship of resources.
8. Promote and maintain care for self and coworkers to foster resilience.
9. Ensure the delivery of safe, compassionate, and high-quality patient care.
THE ENVIRONMENT OF PROGRESSIVE AND CRITICAL CARE NURSES

(AACN, 2019)
1. Acutely and critically ill patients require complex assessment and therapies, high-
intensity interventions, and continuous vigilance.
Professional Caring and Ethical Practice CHAPTER 1 3
2. Progressive care nurses provide direct care or influence care for acutely ill patients

Professional Caring
who are moderately stable with an elevated risk for instability.
3. Critical care nurses provide direct care or influence care for acutely/critically
ill patients who are at high risk for actual or potential life-threatening health
problems, regardless of the setting for their nursing care.
4. Progressive and critical care nurses practice in settings where patients require
complex assessments and interventions. These settings are not defined by the
patient’s location in a designated unit, but by the needs of the patient. Nurses lead
1
and participate in collaborative interprofessional teams to create safe, respectful,
healing, and caring environments in which:
a. Patient and family values and preferences are central to the development of
informed care decisions made in collaboration with and using the expertise of the
interprofessional healthcare team.
b. Ethical decision-making is supported, fostered, and promoted.
c. Nurses are valued and committed partners on the interprofessional team in
decision-making that impacts patient care, the practice environment, and
organizational operations.
d. Nurses act as advocates on behalf of patients, families, and communities.
e. Collaboration and collegiality are embraced.
f. Practice is based on research and best evidence.
g. Leadership skill development is fostered at all levels.
h. Professional and organizational leadership encourages and supports effective
decision-making, lifelong learning, and professional growth.
i. Individual talents and resources are optimized.
j. Innovation, creativity, and clinical inquiry are recognized and valued.
k. Diversity is recognized, supported, and respected.
l. Skilled communication is demonstrated on all levels.
m. A professional practice model drives the delivery of nursing care.
n. Burnout is recognized; self-care and building resilience are supported.
o. Nurses are recognized and recognize others for the value each brings to the work of
the organization.
p. The standards of a healthy work environment are implemented to support the health
and safety of the interprofessional team.
q. Zero tolerance is the standard for inappropriate behavior, bullying, or violent
behavior.
r. Appropriate nurse staffing ensures the matching of patient needs and nurse
competencies to promote safety and quality outcomes (Barden, 2015).
5. Patient safety
a. The National Academy of Medicine (NAM), formerly the Institute of Medicine
(IOM), notes the occurrence of medical errors and adverse medication events
increasing at an alarming rate in the United States as it relates to healthcare service
delivery processes. NAM has published two landmark reports on patient safety
including:
i. To Err is Human: Building a Safer Health System (2000)
ii. Crossing the Quality Chasm: A New Health System for the 21st Century
External Link Disclaimer (2001).
b. The Joint Commission (TJC) first established the National Patient Safety Goals in
2005. For 2020, it includes the following goals.*
*Visit TJC website for the most current goals: http://www.jointcommission.org

i. Improve the accuracy of patient identification by using at least two patient

identifiers when providing care, treatment, and services. This will eliminate
transfusion errors related to patient misidentification.
ii. Improve the effectiveness of communication among caregivers by reporting
critical results of tests and diagnostic procedures on a timely basis to the right
person.
iii. Improve the safety of using medications by labeling all medications, medication
containers, and other solutions on and off the sterile field in perioperative and
other procedural settings. In addition, reduce the likelihood of patient harm
associated with the use of anticoagulant therapy. Maintain and communicate
accurate patient medication information.
iv. Reduce the harm associated with clinical alarm systems by improving the safety
of clinical alarm systems.
v. Reduce the risk of healthcare-associated infections by complying with
either the current Centers for Disease Control and Prevention (CDC) hand
hygiene guidelines or the current World Health Organization (WHO) hand
hygiene guidelines. In addition, implement evidence-based practices to
prevent: (a) healthcare-associated infections because of multidrug-resistant
organisms in acute care hospitals, (b) central line–associated bloodstream
infections (CLABSI), (c) surgical site infections (SSIs), and (d) indwelling
catheter-associated urinary tract infections (CAUTI).
vi. The hospital identifies safety risks inherent in its patient population such as
reduce the risk of suicide, conduct a preprocedure verification process, mark the
procedure site, and perform a time-out before the procedure.
c. The Institute of Healthcare Improvement (IHI, 2020) focuses on making care
continually safer by reducing harm and preventable mortality. IHI’s focus on patient
safety includes:
i. Galvanizing the safety agenda: Spearhead a multiorganizational initiative
to create a national action plan for the prevention of harm in
healthcare.
ii. Engaging leadership in change: Provide strategic guidance and innovative
thinking to help leaders at all levels embrace, create, and implement tools and
strategies that drive change.
iii. Fostering cultures of safety: Provide tactical tools and frameworks to assess
safety culture, identify areas for improvement, and implement system-wide
changes that affect culture.
iv. Building skills: Offer a range of programs to teach key safety and improvement
skills at every level—from students to executives.
d. Agency for Healthcare Research and Quality (AHRQ, 2018) promotes 10 Safety Tips
for Hospitals:
i. Prevent central line-associated bloodstream infections.
ii. Reengineer hospital discharges.
iii. Prevent venous thromboembolism.
iv. Educate patients about using blood thinners safely.
v. Limit shift durations for medical residents and other hospital staff if possible.
vi. Consider working with a Patient Safety Organization.
vii. Use good hospital design principles.
viii. Measure your hospital's patient safety culture.
ix. Build better teams and rapid response systems.
x. Insert chest tubes safely.

KEY CONCEPT
Professional Caring
Patient safety is an essential component in the practice of nursing. Registered nurses protect, pro-
mote, and optimize health and facilitate healing. It is the nurses’ professional obligation to raise
concerns regarding any practices that put patients or themselves at risk of harm. Furthermore, it is the
responsibility of all members of the interprofessional team to ensure that patients receive safe and
compassionate care.
1
THE AACN SYNERGY MODEL FOR PATIENT CARE
1. Synergistic practice and patient and family safety: The AACN Synergy
Model for Patient Care is a conceptual framework that aligns patient needs with
nurse competencies in achieving optimal outcomes and nurse satisfaction. The
model’s premise is that the needs of the patient and their family system drive
the competencies required by the nurse. When this occurs, synergy is produced
and optimal outcomes can be achieved. The synergy created by practice based on
the Synergy Model helps the patient-family unit safely navigate the healthcare
system.
2. The Synergy Model and ethical practice: The Synergy Model provides a
foundation for addressing ethical concerns related to critical care nursing
practice. The model focuses on the characteristics of patients, the competencies
needed by the critical care nurse to meet the patient’s needs based on these
characteristics, and the outcomes that can be achieved through the synergy
that develops when nursing competencies are driven by the patient’s needs.
AACN is committed to helping members deal with ethical issues through
education.
AACN SYNERGY MODEL FOR PATIENT CARE (AACN, 2020a,b,c)

ORIGIN OF THE SYNERGY MODEL
1. In 1992 AACN developed a vision of a healthcare system driven by the needs of
patients and their families in which critical care nurses can make their optimal
contribution. AACN, in conjunction with the Certification Corporation,
reconsidered the contributions of certification to the care of patients. Patient needs
and outcomes must be the central focus of certification. A think tank was convened
to conceptualize certified practice.
PURPOSE
1. Before the development of the Synergy Model, the certification process
conceptualized nursing practice according to the dimensions of the nurse’s role,
the clinical setting, and the patient’s diagnosis. The Synergy Model conceptualized
certified practice to recognize that the needs and characteristics of patients and
families influence and drive the characteristics or competencies of nurses. The
synergy that develops when this occurs influences the outcomes of individual
patients, the nurse’s practice, and the organization.
OVERVIEW OF THE SYNERGY MODEL

1. Description of the Synergy Model (Fig. 1.1): The synergy that occurs when patient
and family characteristics or needs drive the competencies that nurses need to
achieve optimal outcomes for the patient, nurse, and organization.
NURSE PATIENT
PATIENT/FAMILY
COMPETENCIES OUTCOMES
NEEDS
(Synergy)
Resiliency Clinical judgment Comfort and healing

Vulnerability Clinical inquiry Satisfaction with care
Stability Collaboration Absence of
Complexity Systems thinking complications
Predictability Advocacy/moral agency Perceived change in
Resource availability Caring practices function
Participation in care Response to diversity Perceived improvement
Participation in decision- Facilitator of learning in quality of life
making Decreased recidivism
Effective cost–resource
utilization balance
Fig. 1.1 Patient and family characteristics drive nurse competencies to achieve optimal (syner-
gistic) outcomes.
2. Assumptions of the Synergy Model

a. All patients are biologic, psychologic, social, and spiritual entities who have similar
needs and experiences at a particular developmental stage across wide ranges or
continuum from health to illness. The whole patient must be considered.
b. The dimensions of a nurse’s practice as determined by the needs of a patient and
family can also be described along a continuum.
c. The patient, family, and community all contribute to providing a context for the
nurse-patient relationship.
d. Optimal outcomes can be achieved through the synergy resulting in alignment of
nurse competencies with patient and family needs. For example, a peaceful death
can be an acceptable outcome.
3. Patient characteristics: The more critically ill the patient, the more likely he or she
is to be highly vulnerable, unstable, and complex. Acute and critical care nurses’
practice in settings where patients require complex assessment and therapies,
high-intensity interventions, and high-level continuous nursing vigilance. Patient
characteristics in the acutely and critically ill population can be defined along the
continuum described by the Synergy Model (Table 1.1):
a. Resiliency: The capacity to return to a restorative level of functioning using
compensatory coping mechanisms; the ability to bounce back quickly after an insult.
b. Vulnerability: Susceptibility to actual or potential stressors that may adversely affect
patient outcomes.
c. Stability: The ability to maintain a steady-state equilibrium.
d. Complexity: The intricate entanglement of two or more systems (e.g., body, family,
therapies).
e. Resource availability: The body of resources (e.g., technical, fiscal, personal,
psychologic, social) that the patient, family, and community bring to the situation.
f. Participation in care: Extent to which the patient and/or family engages in aspects
of care.
g. Participation in decision-making processes: Extent to which the patient and family
engages in decision-making.
h. Predictability: A summative characteristic that allows one to expect a certain
trajectory of illness.
TABLE 1.1 The Synergy Model: Patient Characteristics

Professional Caring
Characteristic and Description Continuum of Health and Illness
INTRINSIC CHARACTERISTICS
Resiliency Level 1: Minimally resilient
The capacity to return to a • Unable to mount a response
restorative level of functioning using • Failure of compensatory/coping mechanisms
compensatory and coping mechanisms; • Minimal reserves
1
the ability to bounce back quickly after
an insult • Brittle
Level 3: Moderately resilient
• Able to mount a moderate response
• Able to initiate some degree of compensation
• Moderate reserves
Level 5: Highly resilient
• Able to mount and maintain a response
• Intact compensatory/coping mechanisms
• Strong reserves
• Endurance
Vulnerability Level 1: Highly vulnerable
Susceptibility to actual or potential • Susceptible
stressors that may adversely affect • Unprotected, fragile
patient outcomes
Level 3: Moderately vulnerable
• Somewhat susceptible
• Somewhat protected
Level 5: Minimally vulnerable
• Safe; out of the woods
• Protected, not fragile
Stability Level 1: Minimally stable
The ability to maintain a steady-state • Labile; unstable
equilibrium. • Unresponsive to therapies
• High risk of death
Level 3: Moderately stable
• Able to maintain steady state for limited period of time
• Some responsiveness to therapies
Level 5: Highly stable
• Constant
• Responsive to therapies
• Low risk of death
Complexity Level 1: Highly complex
The intricate entanglement of two • Intricate
or more systems (e.g., body, family, • Complex patient/family dynamics
therapies) • Ambiguous/vague
• Atypical presentation
Level 3: Moderately complex
• Moderately involved patient/family dynamics
Level 5: Minimally complex
• Straightforward
• Routine patient/family dynamics
• Simple/clear-cut
• Typical presentation
Continued
TABLE 1.1 The Synergy Model: Patient Characteristics —cont’d

Characteristic and Description Continuum of Health and Illness
Predictability Level 1: Not predictable
A characteristic that allows one to • Uncertain
expect a certain course of events or • Uncommon patient population or illness
course of illness • Unusual or unexpected course
• Does not follow critical pathway or no critical pathway
developed
Level 3: Moderately predictable
• Wavering
• Occasionally noted patient population or illness
Level 5: Highly predictable
• Certain
• Common patient population or illness
• Usual and expected course
• Follows critical pathway
EXTRINSIC CHARACTERISTICS
Resource availability Level 1: Few resources
Extent of resources (e.g., technical, • Necessary knowledge and skills not available
fiscal, personal, psychologic, and • Necessary financial support not available
social) the patient, family, and • Minimal personal/psychologic supportive resources
community bring to the situation
• Few social systems resources
Level 3: Moderate resources
• Limited knowledge and skills available
• Limited financial support available
• Limited personal/psychologic supportive resources
• Limited social systems resources
Level 5: Many resources
• Extensive knowledge and skills available and
accessible
• Financial resources readily available
• Strong personal/psychologic supportive resources
• Strong social systems resources
Participation in care Level 1: No participation
Extent to which patient and/or family • Patient and/or family unable or unwilling to participate
engage in aspects of care in care
Level 3: Moderate participation
• Patient and/or family need assistance in care
Level 5: Full participation
• Patient and/or family fully able and willing to participate
in care
Participation in decision-making Level 1: No participation
Extent to which patient and/or family • Patient and/or family have no capacity for decision-making;
engages in decision-making require surrogacy
Level 3: Moderate participation
• Patient and/or family have limited capacity; seek input/advice
from others in decision-making
Level 5: Full participation
• Patient and/or family have capacity, and make decisions
themselves
From American Association of Critical-Care Nurses (AACN), 2020. AACN synergy model for patient care. Retrieved from https://
www.aacn.org/nursing-excellence/aacn-standards/synergy-model.
4. Nurse characteristics: Nursing care is an integration of knowledge, skills,

Professional Caring
experience, and individual attitudes. The type of nurse characteristics is derived
from the patient’s needs and range from a competent to expert level (Table 1.2).
a. Clinical judgment: Clinical reasoning, which includes clinical decision-making,
critical thinking, and a global grasp of the situation, coupled with nursing skills
acquired through a process of integrating education, experiential knowledge, and
evidence-based guidelines.
b. Advocacy/moral agency: Working on another’s behalf and representing the concerns
1
of the patient/family and nursing staff; serving as a moral agent in identifying and
helping to resolve ethical and clinical concerns within and outside the clinical
setting.
TABLE 1.2 The Synergy Model: Nurse Characteristics

Level of Expertise (Levels 1 to 5 Range From
Characteristic and Description Competent to Expert)
Clinical judgment Level 1
Clinical reasoning, which includes clinical • Collects and interprets basic-level data
decision-making, critical thinking, and a • Follows algorithms, protocols, and pathways with all
global grasp of the situation coupled with populations and is uncomfortable deviating from them
nursing skills acquired through a process • Matches formal knowledge and clinical events to make
of integrating education, experiential basic care decisions
knowledge, and evidence-based guidelines • Questions the limits of one’s ability to make clinical
decisions and defers the decision-making to other
clinicians
• Recognizes expected outcomes
• Often focuses on extraneous details
Level 3
• Collects and interprets complex patient data focusing on
key elements of case; able to sort out extraneous detail
• Follows algorithms, protocols, and pathways and is
comfortable deviating from them with common or routine
patient population
• Recognizes patterns and trends that may predict the
direction of illness
• Recognizes limits and uses appropriate help
• Reacts to and limits unexpected outcomes
Level 5
• Synthesizes and interprets multiple, sometimes conflicting,
sources of data
• Makes judgments based on an immediate grasp of the “big
picture,” unless working with new patient populations;
uses past experiences to anticipate problems (applies
principles from old situations to new situations)
• Helps patient and family see the “big picture”
• Recognizes the limits of clinical judgment and seeks
interprofessional collaboration and consultation with
comfort
• Recognizes and responds to the dynamic situation
(following patient/family lead)
• Anticipates unexpected outcomes
• Acts on and directs others to act on identified clinical
problems
• Assists nursing staff in identifying daily goals for patients
Continued
TABLE 1.2 The Synergy Model: Nurse Characteristics —cont’d

Advocacy/moral agency Level 1
Working on another’s behalf and representing • Works on behalf of the patient and self
the concerns of the patient/family and Begins to self-assess personal values
nursing staff; serving as a moral agent in • Aware of ethical conflicts/issues that may surface in
identifying and helping to resolve ethical clinical setting
and clinical concerns within and outside the • Makes ethical/moral decisions based on rules/guiding
clinical setting principles and on own personal values
• Represents patient if consistent with own framework
• Aware of patient rights
• Acknowledges death as an outcome
Level 3
• Works on behalf of patient and family
• Considers patient values and incorporates in care even
when differing from personal values
• Supports patients, families, and colleagues in ethical and
clinical issues; identify internal resources
• Moral decision-making can deviate from rules
• Demonstrates give and take with patients/family, allowing
them to speak/represent themselves when possible
• Aware of and acknowledges patient and family rights
• Recognizes that death may be an acceptable outcome
• Facilitates patient/family comfort in the death and dying
process
Level 5
• Works on behalf of patient, family, and community
• Advocates from patient/family perspective, whether similar
to or different from personal values
• Advocates for resolution of ethical conflict and issues
from patient, family, or colleague’s perspective; uses and
participates in internal and external resources
• Recognizes rights of patient/family to drive moral decision-
making
• Empowers the patient and family to speak for/represent
themselves
• Achieves mutuality within patient/family/professional
relationships
Caring practices Level 1
Nursing activities that create a • Focuses on basic and routine needs of the patient
compassionate, supportive, and therapeutic • Bases care on standards and protocols
environment for patients and staff with • Maintains a safe physical environment
the aim of promoting comfort and healing Level 3
and preventing unnecessary suffering. • Responds to subtle patient and family changes
These caring behaviors include but are • Engages with the patient to provide individualized care
not limited to vigilance, engagement, and • Uses caring and comfort practices to provide individualized
responsiveness. Caregivers include family care for patient/family
and healthcare personnel. • Optimizes patient/family environment
Level 5
• Has astute awareness and anticipates patient/family
changes and needs
• Fully engaged with and senses how to stand alongside the
patient/family and community
• Patient/family needs determine caring practices
• Anticipates hazards, and promotes safety, care, and comfort
throughout transitions along the healthcare continuum

Professional Caring
• Initiates the establishment of an environment that
promotes caring
• Provides patient/family the skills to navigate transitions along
the healthcare continuum (e.g., facilitates safe passage)
1
Collaboration Level 1
Working with others (e.g., patients, families, • Willing to be taught, coached, and/or mentored
healthcare providers) in a way that promotes • Participates in team meetings and discussions regarding
each person’s contributions toward achieving patient care and/or practice issues
optimal and realistic patient/family goals. • Open to various team members’ contributions
Collaboration involves interprofessional work Level 3
with colleagues and community. • Willing to be taught/mentored
• Participates in precepting and teaching
• Initiates and participates in team meetings and discussions
regarding patient care and/or practice issues
• Recognizes and critiques interprofessional participation in
care decisions
Level 5
• Seeks opportunities to role model, teach, mentor, and to be
mentored
• Facilitates active involvement and contributions of others
in team meetings and discussions regarding patient care
and/or practice issues
• Involves/recruits interprofessional resources to optimize
patient outcomes
• Role models, teaches, and/or mentors professional
leadership and accountability for nursing’s role within the
healthcare team and community
Systems thinking Level 1
Body of knowledge and tools that allow the • Uses previously learned strategies or standardized
nurse to manage whatever environmental processes
and system resources exist for the patient/ • Identifies problems but unclear of healthcare systems to
family and staff, within or across healthcare resolve problems
and nonhealthcare systems. • Sees patient and family within the isolated environment of
the unit
• Sees self as key resource for patient/family
• Applies personal experiences to identify patient/family needs
Level 3
• Develops processes/strategies based on needs and
strengths of patient/family
• Able to make connections within pieces or components of
the healthcare system
• Sees and begins to use negotiation as a tool for practice-
based decisions
• Recognizes and reacts to needs of patient/family as they
move through healthcare systems
• Recognizes how to obtain and use resources within the
healthcare system
Level 5
• Develops, integrates, and applies a variety of strategies that
are driven by the needs and strengths of the patient/family
• Recognizes global or holistic interrelationships that exist
within and across both healthcare and nonhealthcare systems
• Knows when and how to negotiate and navigate through
the system on behalf of patients and families
Continued

• Develops core plans based on anticipated needs of
patients/families
• Uses a variety of resources as necessary to optimize
patient/family outcomes
Response to diversity Level 1
The sensitivity to recognize, appreciate, and • Assesses diversity and acknowledges differences but uses
incorporate differences into the provision of standardized plans of care
care. Differences may include, but are not • Provides care based on own belief system
limited to, cultural, spiritual, gender, race, • Practices within the culture of the healthcare environment
ethnicity, lifestyle, socioeconomic, age, and • Recognizes barriers
values. • Recognizes practices based upon diversity that have
potential negative outcomes
Level 3
• Inquiries about cultural differences and considers their
effect on care
• Accommodates personal and professional differences in
plans of care
• Helps patient/family understand the culture of the
healthcare system
• Recognizes barriers and seeks strategies for resolution
• Identifies and uses resources that promote and support diversity
Level 5
• Anticipates needs of patient/family based on identified
diversities and develops plans accordingly
• Acknowledges and incorporates differences
• Adapts healthcare culture, to the extent possible, to meet
the diverse needs and strengths of the patient/family
• Anticipates and intervenes to reduce/eliminate barriers
• Incorporates patient/family values with evidence-based
practice for optimal outcomes
Clinical inquiry Level 1
The ongoing process of questioning and • Follows policies, procedures, standards, and guidelines
evaluating practice and providing informed without deviation
practice; creating changes through evidence- • Uses research-based practices as directed by others
based practice, research utilization, and • Recognizes the need for further learning to improve patient care
experiential knowledge. • Recognizes obvious changing patient situation (e.g.,
deterioration, crisis) and seeks assistance to identify
patient problems and solutions
• Participates in data collection (e.g., research, quality
improvement, evidence-based practice)
Level 3
• Uses policies, procedures, standards, and guidelines,
adapting to patient needs
• Applies research findings when not in conflict with current
clinical practice
• Accepts advice or information to improve patient care
• Recognizes subtle changes in patient condition and begins
to compare and contrast possible care alternatives
• Participates on team (e.g., CQI, survey, research)
Level 5
• Improves, modifies, or individualizes policies, procedures,
standards, and guidelines for particular patient
situations or populations based on experiential or
published data

Professional Caring
• Questions and/or evaluates current practice based on
patient/family’s responses, review of the literature,
research, and education/learning
• Seeks to validate whether research answers clinical
questions
1
• Embraces lifelong learning and acquires knowledge and
skills needed to address questions arising in practice to
improve patient care
• Evaluates outcomes of studies and implements changes
(converging of clinical inquiring and clinical judgment
allows for anticipation of patient needs)
Facilitator of learning Level 1
The ability to facilitate learning for patients • Follows planned educational programs using standardized
and families, nursing staff, other members educational materials
of the healthcare team, and community; • Sees patient/family education as a separate task from
includes both formal and informal facilitation delivery of care
of learning. • Provides information without seeking to assess learner’s
readiness or understanding
• Has basic knowledge and/or understanding of the patient/
family’s educational needs
• Focuses educational plan on nurse-identified patient/family
needs
• Sees the patient/family as a passive recipient
Level 3
• Adapts planned educational programs to meet individual
patient’s needs
• Begins to recognize and integrate different ways of
implementing education into delivery of care
• Assesses patient’s/family’s readiness to learn, develops
education plan based on identified needs, and evaluates
learner understanding
• Recognizes the benefits of educational plans from different
healthcare providers’ perspectives
• Sees the patient/family as having input into educational goals
• Incorporates patient’s/family’s perspective into
individualized education plan
Level 5
• Creatively modifies or develops patient/family education
programs
• Integrates patient/family education throughout delivery of
care
• Evaluates patient/family readiness to learn and provides
comprehensive individualized education evaluating
behavior changes related to learning, adjusting to meet the
educational goal
• Collaborates and incorporates all healthcare providers’
ideas into ongoing educational plans for the patient/family
• Sees patient/family as having choices and consequences
that are negotiated in relation to education
From American Association of Critical-Care Nurses (AACN), 2020. AACN synergy model for patient care. Retrieved from https://
www.aacn.org/nursing-excellence/aacn-standards/synergy-model.
c. Caring practices: Nursing activities that create a compassionate, supportive, and

therapeutic environment for patients and staff with the aim of promoting comfort
and healing and preventing unnecessary suffering. These caring behaviors include
but are not limited to vigilance, engagement, and responsiveness. Caregivers include
family and healthcare personnel.
d. Collaboration: Working with others (e.g., patients and families, healthcare providers)
in a way that promotes each person’s contributions toward achieving optimal and
realistic patient and family goals. Collaboration involves interprofessional work with
colleagues and community.
e. Systems thinking: The body of knowledge and tools that allow the nurse to manage
whatever environmental and system resources exist for the patient, family, and staff
within or across healthcare and nonhealthcare systems.
f. Response to diversity: The sensitivity to recognize, appreciate, and incorporate
differences into the provision of care. Differences may include, but are not limited to,
cultural, spiritual, gender, race, ethnicity, lifestyle, socioeconomic, age, and values.
g. Clinical inquiry or innovation and evaluation: The ongoing process of questioning and
evaluating practice and providing informed practice; creating changes through evidence-
based practice, research utilization, and experiential knowledge (Melnyk et al., 2014).
h. Facilitator of learning: The ability to facilitate learning for patients and families,
nursing staff, other members of the healthcare team, and community; includes both
formal and informal facilitation of learning.
5. Outcomes of patient-nurse synergy (Fig. 1.2)
a. Patient-derived outcomes
i. Behavior change: Based on the dispensing and receiving of information.
Requires caregiver trust. Patients and families grow in their knowledge about
health and take greater responsibility for their own health.
ii. Functional change and quality of life: Interprofessional measures that can be
used across all populations of patients but provide specific information to a
population of patients when analyzed separately.
iii. Satisfaction ratings: Subjective measures of individual health and quality of
health services. Satisfaction measures query about expectations (technical care
provided, trusting relationships, and education experiences) and the extent to
which they are met. Often linked with functional change and quality-of-life
perceptions.
iv. Comfort ratings and perceptions: Quality-of-care outcomes based on caring
practices with the aim of promoting comfort and alleviating suffering.
b. Nurse-derived outcomes
i. Physiologic changes: Require monitoring and managing instantaneous therapies
and noting changes. The nurse expects a specific trajectory of changes when he
or she “knows” the patient.
ii. The presence or absence of preventable complications: Through vigilance and
clinical judgment, the nurse creates a safe and healing environment.
iii. Extent to which care and treatment objectives were attained: Reflects the nurse’s
role as an integrator of care that requires a high degree of collaboration.
c. System-derived outcomes
i. Recidivism: Decrease in readmission, which adds to the personal and financial
burden of care.
ii. Cost and resource utilization: Organizations usually evaluate financial cost
based on an episode of care. Achieving cost-effective care requires knowing the
patient and providing continuity of care. Resource utilization can affect patient

Professional Caring
1
Fig. 1.2 Three levels of outcomes delineated by the AACN Synergy Model for Patient Care:
Those derived from the patient, those derived from the nurse, and those derived from the
healthcare system. (Reprinted from Curley, M. (1998). Patient-nurse synergy: optimiz-
ing patients’ outcomes. American Journal of Critical Care, 7, 69. © American Association of
Critical-Care Nurses. All rights reserved. Figure adapted with permission.)
outcomes when there is not enough care given by competent nurses. When
nurses cannot provide care at an appropriate level to meet patient needs, they
are dissatisfied and turnover is high, which results in increased costs for the
organization (Ulrich et al., 2019).
APPLICATION OF THE SYNERGY MODEL

1. The Synergy Model is the keystone of AACN certifications. It is also used as a
professional practice model, a foundation for nursing school curricula and a model
for professional advancement. There are many applications for the model in clinical
operations, clinical practice, education, and research:*
a. Clinical operations
i. Leadership: Using the model for organizational infrastructure for achieving
excellence in practice, improving financial outcomes, and establishing clinical
advancement programs.
*Refer to the AACN website for up-to-date application of the Synergy Model for Patient Care: https://www.aacn.org/
nursing-excellence/aacn-standards/synergy-model.
ii. Development of continuity-of-care models.

iii. Foundation model for family-centered care practice.
iv. Basis for making care assignments and making nursing rounds.
b. Clinical practice
i. Development of clinical strategies.
ii. Direct patient care.
iii. AACN is developing an approach to nursing competence based on the
Synergy Model. The core focus is the introduction of Synergy Nurse
Competencies as an essential part of nursing competence, both at the level of
entry to practice on a nursing unit and in continuing competence. The eight
nurse characteristics described in the preceding section are adapted to define
the knowledge and skill the nurse needs to demonstrate in practice, applicable
across all.
c. Education
i. Basis for critical care registered nurse (CCRN) and acute/critical care clinical
nurse specialist (CCNS) certification examinations since 1999.
ii. Potential use as a foundation for education of healthcare teams.
d. Research
i. Validated in the AACN Certification Corporation Study of Practice.
ii. Underwent theoretical review.
iii. Further research needed related to consumer perspective, staffing and
productivity implications for nursing, patient outcomes measurement, and
development of a quantitative tool based on the model for rapidly assessing
patients and determining nursing characteristics.
KEY CONCEPT
AACN Synergy Model for Patient Care accounts for the needs and characteristics of patients and
families, which then drive the characteristics or competencies of nurses. Synergy results when
the needs and characteristics of a patient, clinical unit, or system are matched with a nurse’s
competencies.
FAMILY PRESENCE: VISITATION IN THE ADULT ICU (AACN PRACTICE

ALERT, 2016)
1. Evidence shows that the unrestricted presence and participation of a support
person (e.g., family as defined by the patient) can improve the safety of care and
enhance patient and family satisfaction. This is especially true in the intensive
care unit (ICU), where the patients are usually intubated and cannot speak for
themselves.
2. Family presence can improve communication, facilitate a better understanding
of the patient, advance patient- and family-centered care, and enhance staff
satisfaction.
3. Families and other partners are welcomed 24 hours a day according to the patient’s
preference.
EXPERT TIP
The use of the AACN Practice Alert can direct nurses to the evidence of Family Visitation in the Adult
ICU.
HEALTHY WORK ENVIRONMENT STANDARDS (AACN, 2016)

Professional Caring
1. AACN believes that all workplaces can be healthy if nurses and employers are
resolute in their desire to address not only the physical environment but also
less tangible barriers to staff and patient safety. The ingredients for success are
described in the AACN Standards for Establishing and Sustaining Healthy Work
Environments:
a. Skilled communication: Nurses must be as proficient in communication skills as
1
they are in clinical skills.
b. True collaboration: Nurses must be relentless in pursuing and fostering true
collaboration.
c. Effective decision-making: Nurses must be valued and committed partners in
making policy, directing and evaluating clinical care, and leading organizational
operations.
d. Appropriate staffing: Staffing must ensure the effective match between patient needs
and nurse competencies.
e. Meaningful recognition: Nurses must be recognized and must recognize others for
the value each brings to the work of the organization.
f. Authentic leadership: Nurse leaders must fully embrace the imperative of a healthy
work environment, authentically live it, and engage others in its achievement.
EXPERT TIP
A web-based Healthy Work Environment Assessment Tool is available to collectively measure
your work environment’s current health. Learn more at https://www.aacn.org/nursing-excellence/
healthy-work-environments.
GENERAL LEGAL CONSIDERATIONS RELEVANT TO CRITICAL CARE

NURSING PRACTICE
NATIONAL GOVERNING BODIES
1. TJC accredits more than 22,000 healthcare organizations and programs in the
United States. A majority of state governments recognize TJC accreditation as a
condition of licensure and the receipt of Medicare and Medicaid programs (https://
www.jointcommission.org).
2. National Council of State Boards of Nursing (NCSBN) is a not-for-profit
membership organization comprised of the State Boards of Nursing. It collaborates
with the state boards on matters of common interest and concern affecting
public health, safety, and welfare including the development of nursing licensure
examinations (https://www.ncsbn.org/index.htm).
3. The American Nurses Credentialing Center (ANCC) gives Magnet accreditation to
hospitals that demonstrate nursing excellence (https://www.nursingworld.org/ancc/).
STATE NURSE PRACTICE ACTS (Russell, 2017)

1. Purpose: To protect the public.
2. Statutory laws: Written by the individual states.
3. Usual authorization: Board of nursing to oversee nursing (by use of regulations or
administrative law).
4. Content: Define scope of practice for nurses.
SCOPE OF PRACTICE
1. Provides guidance for acceptable nursing roles and practices, which vary from state
to state.
a. Nurses are expected to follow the nurse practice act and not deviate from usual
nursing activities.
b. Advanced nursing practice: Expanded roles for nurses include nurse practitioner,
clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-
midwife. These roles require education beyond the basic nurse education and
usually involve a master’s degree. Certain responsibilities associated with these roles
are not interchangeable (ANA, 2020).
c. Based on the Synergy Model, a scope and standards for acute care nurse practitioner
practice (2017) and acute care clinical nurse specialist practice (2014) was published
by AACN.
STANDARDS OF CARE
1. A standard of care is any established measure of extent, quality, quantity, or value;
an agreed-upon level of performance or a degree of excellence of care that is
established.
2. Standards are established by usual and customary practice, institutional guidelines,
association guidelines, and legal precedent.
3. Standards of care, standards of practice, policies, procedures, and performance
criteria all establish an agreed-upon level of performance or degree of excellence.
a. ANA standards: The ANA has generic standards and also specialty standards (e.g.,
for medical-surgical nursing).
b. AACN scope and standards for acute and critical care nursing practice.
c. AACN scope and standards for acute care clinical nurse specialist practice.
d. AACN scope and standards for acute care nurse practitioner practice.
4. National facility standards: Include those published by TJC and the National
Committee for Quality Assurance (NCQA).*
5. Community and regional standards: Standards prevalent in certain areas of the
country or in specific communities.
6. Hospital and medical center standards: Standards developed by institutions for
their staff and patients.
7. Unit practice standards, policies, and protocols: Specific standards of care for
specific groups or types of patients or specific procedures (e.g., insulin or massive
blood transfusion protocols).
8. Precedent court cases: Standard of a “reasonable prudent nurse” (e.g., what a
reasonable prudent nurse would have done in the given situation).
9. Other nursing and interprofessional specialty organization standards: The
American Heart Association, the Society of Critical Care Medicine, and the
Association of periOperative Registered Nurses.
KEY CONCEPT
Nurses provide care in a variety of healthcare settings. All nurses have the right to practice in work
environments that support and allow them to act in accordance with professional and legal standards
(ANA, 2020).
*NCQA website contains the various standards the committee endorses and/or publishes: http://www.ncqa.org
CERTIFICATION IN A SPECIALTY AREA

Professional Caring
1. Certification is a process by which a nongovernmental agency, using predetermined
standards, validates an individual nurse’s qualification and knowledge for practice
in a defined functional or clinical area of nursing.
2. A common goal of specialty certification programs is to promote consumer
protection and to promote high standards of practice.
3. The certified nurse may be held to a higher standard of practice in the specialty
than the noncertified nurse; certification validates the nurse’s knowledge in a
1
specialty area.
4. Critical care certifications are awarded by AACN Certification Corporation,
established in 1975. AACN Certification Corporation is accredited by the National
Commission for Certifying Agencies, the accreditation arm of the National
Organization for Competency Assurance.
a. The AACN Certification Corporation develops and administers the CCRN, CCRN-E,
CCRN-K, PCCN, ACNPC, ACNPC-AG, CCNS, ACCNS-AG, ACCNS-P, and
ACCNS-N specialty examinations, and the CMC and CSC subspecialty examinations.
b. CCRN certification: Separate certification processes for critical care nurses
practicing with neonatal, pediatric, or adult populations.
c. CCNS certification: Advanced practice certification of nurses in acute care clinical
nurse specialist practice. Separate certification processes for CNSs practicing with
neonatal, pediatric, or adult populations.
d. ACNPC and ACNP-AG certification: Advanced practice certification of acute care
nurse practitioners. Separate certification processes for ACNPs practicing with adult
and adult-geriatric populations.
5. Certification provides patients and families with validation that the nurses caring
for them have demonstrated knowledge that exceeds that which is assessed in entry-
level licensure examinations (AACN Certification Corporation, 2020a,b,c).
a. Certification has been linked to patient safety.
b. Units with higher numbers of certified nurses reported lower frequency of falls or
pressure ulcer development.
c. Certification has also been linked to patient satisfaction, from both patients’ reports
and nurses’ perceptions.
PROFESSIONAL LIABILITY
1. Professional negligence: An unintentional act or omission. It is the failure to do
what the reasonable prudent nurse would do under similar circumstances, or an
act or failure to act that leads to an injury of another. Six specific elements are
necessary for professional negligence action and must be established by a person
bringing a suit against a nurse (plaintiff):
a. Duty: To protect the patient from an unreasonable risk of harm.
b. Breach of duty: Failure by a nurse to do what a reasonable prudent nurse would do
under the same or similar circumstances. The breach of duty is a failure to perform
within the given standard of care. The standard defines the nurse’s duty to the patient.
c. Proximate cause: Proof that the harm caused was foreseeable and that the person
injured was foreseeably a victim. This element can determine the extent of damages
for which a nurse may be held liable.
d. Injury: The harm done.
e. Direct cause of injury: Proof that the nurse’s conduct was the cause of or contributed
to the injury to the patient.
f. Damages: Proof of actual loss, damage, pain, or suffering caused by the nurse’s conduct.
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showed a disposition to treat; and, false throughout, gave assurances
that he would not assume the offensive on any point. “Our latest
intelligence,” says M. Drouyn de Lhuys, so recently as the 15th
December—“our latest intelligence from St Petersburg is to the effect
that Russia is resolved to treat, and, above all, to adopt no offensive
measures, and our confidence in this may suffice to explain the
inactivity of the fleets.” But the pacific declarations of Russia, which
we fear M. Castelbajac too readily believed, were but the cloak under
which the attack on the Turkish squadron of Sinope, and the
massacre which followed, were concealed. With such a deed
perpetrated at so short a distance from the spot where the flags of
England and France were floating together, the fleets could not
linger any more in the Bosphorus. They entered the Black Sea, and
what was termed a policy of action commenced. Prussia and Austria
were startled from their propriety, but they still followed on in the
pursuit of that peace which, when nearest, always eluded their grasp,
—and
“Like the circle bounding earth and skies,
Allures from far, yet, as they follow, flies.”
The attitude of France and England became more decided, and at

length, after much hesitation, the Russian ambassadors were
recalled from Paris and London.
In the course of the long operation which preceded the rupture of
diplomatic relations, the judgment of M. Drouyn de Lhuys appeared
nowhere to greater advantage than in the accuracy with which he
divined and unmasked the real designs of the Czar in the matter of
the Holy Shrines, while our noble Premier looked on credulous and
confiding. The anger of the Czar, so much out of proportion to the
offence, had, to be sure, something suspicious in it, and to the
uninitiated or unsuspecting was utterly inexplicable. M. Drouyn de
Lhuys knew well the cause of that immense wrath. It was not on
account of the miserable squabbles of Latin and Greek monks that
vast bodies of troops traversed the plains of southern Russia, that
stores sufficient for an immense army and for a long campaign were
accumulated in the magazines of Odessa, and that vast preparations
were made at Sebastopol.
The absorbing interest which attached to events in western Europe
since the revolution of 1848—the revolution which had convulsed
nearly every Continental state—had occupied the public mind to the
exclusion of everything else; and Russia availed herself of the storm
which raged everywhere, except in her own territory, to realise her
aggressive projects. Her political and religious influence had long
been paramount at Constantinople. The arrival of M. de Lavalette
first threatened to disturb that monopoly. Indeed, any allusion,
however slight, to the capitulation of 1741, instantly alarmed Russia;
and Prince Menschikoff, finding that the secret of the Czar was
discovered, hastened to present his ultimatum, with all the
aggravating and insulting circumstances already known. The French
Government explained at length to the Cabinet of St Petersburg the
motives and the extent of the French demands with reference to the
Holy Places; but the Head of the Orthodox Church refused to listen—
he would bear no rival in the East. “There is established,” said M.
Drouyn de Lhuys in his despatch of the 21st March to General
Castelbajac, “an important political usage in Europe. It consists in
this, that the Powers interest themselves in common in certain
general interests, and overcome, by means of their diplomacy,
difficulties which at another period could only be terminated by force
of arms. Be so good, then, General, as to demand of M. de Nesselrode
if the Cabinet of St Petersburg, repudiating the principle which has
prevailed for thirty years in the relations of the great Powers with
each other, means to constitute itself the sole arbiter of the destinies
of Turkey, and if for that common policy, to which the world is
indebted for its repose, Russia means to substitute a policy of
isolation and domination which would necessarily constrain the
other Cabinets in the approaching crisis to consult only their own
interests, and to act only with a view to their private views.” Russia
did not choose to comprehend the full significance of that
intimation; and though she herself had often been among the first to
solicit a European combination when there appeared a chance of her
deriving advantage from it, she yet haughtily rejected the proposal
when it crossed, or did not promote, her ambition. Her great object
was to treat with Turkey without the intervention of a third party;
and it was the arrogant manner in which she met the advances of the
Western Powers, or rather forbade them to meddle in what she
regarded as a domestic quarrel between a vassal and his master, that
attracted general attention to the question, and gave it a European
character. We find no point more strongly insisted on by M. Drouyn
de Lhuys, in his despatches to General Castelbajac, than not
permitting Russia to assume this exclusive right of dictating her will
on the Oriental question. It is superfluous to say that France had no
intention of excluding her from a fair share; but beyond that she
would not go. Fearing the probability of a cordial union between
England and France—an event which, so long as Lord Aberdeen
directed the affairs of state, he would not believe possible—the whole
force of the Emperor’s policy was directed to prevent it, or break it
off if it had been already formed. Heretofore the Czar had fully
approved the conduct of his noble friend, and we find more than
once, in the papers laid before Parliament, the warm expression of
imperial gratitude. Happy minister! It falls to the lot of few to be
enabled to boast of such certificates of conduct as those from Louis
Philippe in 1846, and from Nicholas in 1853. It is true that the
excellent qualities so much admired rendered it easy for a hypocrite
to overreach, and an overbearing despot to insult, England. The
English and French alliance must be broken off at any cost. The
insults to the French Emperor, and the French people, were still
ringing in the ears of the public. The impertinencies of two members
of the Aberdeen Cabinet—the wriggling of miserable sycophancy
which met with the contempt it merited—when alluding to the ruler
of France, were fresh in the memory of all. The invasion fever had
not been entirely allayed; the old suspicions of the insincerity of the
French Government, and the jealousies and hatreds which had been
dormant, might again be roused. France must be isolated, and the
partisans of the Orleans family, the “Fusionists,” or by whatever
nickname they are known, already exulted in the shame which they
invoked at the hand of a foreign despot on their own country. The
Chancellor of the Russian Empire brought all his ability to the task.
He accused France of ambition, and reproached her with being the
cause of the quarrel by her conduct in the question of the Holy
Places. The point was a sore one, as, however disingenuously it was
revived by Russia, it was nevertheless a fact that the quarrel followed
hard on the demands of M. de Lavalette. M. de Nesselrode, with true
Muscovite candour, omitted to add that he himself had expressed his
satisfaction and approbation of the fair and honourable manner in
which the French Government had brought that question to an issue.
That account had been finally closed. A considerable portion of the
despatches of M. Drouyn de Lhuys is taken up with a refutation of
those charges, and it is admitted on all hands that his refutation of
them is satisfactory and complete. With the history of Russian
aggression for the last century before us, the charge of ambition
against another power was strange in the mouth of a Russian
minister. But the capitulation of 1741, which confirmed the previous
immunities of the Latin communion in the East, were not, after all,
of a nature to offend or alarm any one. The sort of protectorate which
they established, was not menacing to any power in Europe,
inasmuch as they applied to establishments which were under the
protection of all alike; whilst the Greek protectorate was of the most
exclusive character, and, as has been shown in a previous article, was
not religious, but political, and aimed at placing the whole Ottoman
Empire at the feet of Russia.
Another point which M. Drouyn de Lhuys has handled
successfully, is that which relates to the difference in the measures
adopted in common by France and England, when affairs reached a
most alarming point, and those which Russia, in the impatience of
her ambition, adopted, at the very outset. In the despatch of the 11th
June, General Castelbajac is enjoined to apprise the Russian
Government of the position in which it was about to place itself with
respect to the rest of Europe; to warn it that it was grievously
mistaken if it counted upon allies in the realisation of its designs, and
particularly upon the German states. Indeed, it was not probable that
these states would see with indifference the Lower Danube in the
possession of a powerful government, which might at will obstruct its
navigation, and at any moment block up a commercial outlet of so
much importance. The French Minister clearly showed that the
conduct of Russia was in opposition to the general interests of
Europe; and that the realisation of the doctrines of the Russian
Chancellor meant, in point of fact, the subjugation of the weaker
states to the will of one great power. The replies of M. de Nesselrode
are, of course, replete with the same pacific declarations which had
produced so soporific an effect on our own Government, and with
solemn denials of ambitious views, which present a curious contrast
with the warlike preparations which were never for a moment
suspended except by difficulties independent of the will of Russia. It
was soon seen that, coûte qui coûte, Russia was determined not to
give way. Smooth and hypocritical, like a thief at the bar, who profits
by the scantiness of the evidence at first brought against him,
earnestly to protest his innocence, she became bold, insolent, and
defying, like the same culprit when accumulated proofs leave no
doubt of his guilt. There are some despatches that have not been
inserted in the Moniteur, but we have little doubt that the omitted
ones are not less moderate, less firm, and not less characterised by
good sense and dignity, than those we have noticed; and if any such
doubt existed, the ultimatum, which was at once followed by a
complete rupture of diplomatic relations, would suffice to remove it.
Towards the close of December all was over. The massacre of Sinope
had taken place, and no further hope remained of obtaining any
satisfactory result from a power which, in its diplomacy as its
hostility, appeared to have all at once lost every sentiment of truth,
justice, and humanity. The autograph letter of the Emperor
Napoleon is little more than a summary of the despatch of the 25th
December, of the notes addressed to M. de Kisseleff before his
departure from Paris, and of the last letter of M. Drouyn de Lhuys to
the French ambassador at St Petersburg.
We believe the Emperor of Russia to have been led into his present
difficult position—a position from which escape, unless through a
disastrous war, seems almost impossible—by the erroneous
information he received with respect to the state of public feeling in
France and England, from “antiquated imbecilities” of both
countries. In ordinary times it would be no easy task to so impose on
any person of intelligence, even much inferior to that of the Emperor
Nicholas; and his facility of belief in the present instance can only be
explained by the social and political complications supposed to exist
in a country which has gone through so many violent changes. Under
the regime of Louis Philippe, the female diplomatists of the Rue St
Florentin were enabled to ascertain with accuracy, and communicate
with fidelity, the secret policy of the Tuileries. In the Russian salons
of Paris, the centre of the more important espionage, were nightly
assembled ministers, ex-ministers, functionaries past and present,
and, in fine, all who, in official parlance, were supposed to represent
France. The secrets, the gossip, the scandal of every political coterie
in the capital, were discharged, there, as in one common reservoir;
and were thence transmitted for the information, or amusement, of
the Imperial Court of Russia. The ministers of the citizen-king were
too eager to propitiate the favour of the northern Court, to withhold
their confidence from any of the Czar’s agents, official or non-official.
The revolution of February rudely interfered with that machinery,
directed by a well-known intrigante. Attendance at a half-dozen
saloons no longer sufficed to obtain a knowledge of the state of the
country. Whilst a dozen dowagers of the old schools, and as many
retired, discontented, or broken-down statesmen, and a few amateur
republicans, were indulging in reveries of a restoration, or the re-
establishment of a convention, with its appendages of committees of
public safety, the dream was broken by the acclamations of millions,
who bestowed absolute power on the only man capable of saving
them. The Cabinet of St. Petersburg could not be expected to know
more about the country than those who had for so many years
administered its affairs. The agents of Russia beheld the struggle that
had been going on so long among political coteries, the selfish
disputes of discarded placemen, and their ephemeral and hollow
reconciliations; and they supposed that, because adventurers
quarrelled, or political coteries made war on each other, the nation
was similarly divided. The diplomatic communications of that period
must be curious; and we confess we should like to be permitted a
perusal of the confidential correspondence of the well-known
diplomate in petticoats, who for so many years was the pet agent of
the Czar, and for whom existence was valueless unless passed in the
atmosphere of political intrigue, to which it had been so long
accustomed. When speaking of confidential correspondence, we do
not, of course, allude to those indecent libels penned daily in the
French capital; and, we regret to say, with the knowledge, or under
the superintendence, of persons who, though known for profligacy in
private life, were the confidential companions and bosom friends of
personages whose praises we have heard, even to satiety, for
austerity of morals, and who are held up as samples of every public
and private virtue. Those chroniclers of scandal spared neither sex,
nor age, nor rank. The meanest agency was set to work to furnish
amusement for the Cabinet of the Czar during his hours of
recreation; and to record stories and anecdotes in the style and
manner of Taillement des Réaux, the Œil de Bœuf, or the Chevalier
de Faublas. With such unerring guides, it is no wonder that the Czar
believed that the propitious moment was come. It was represented to
him that the Court of Paris was more corrupt, more profligate, than
that of Louis XV.; that all France was impoverished, degraded, and
discontented, anxious to throw off the yoke of the Buonaparte, eager
to receive a sovereign flung to it by any foreign despot; or, at all
events, utterly incapable of resisting any encroachment, much less
avenging any insult from abroad. The ruler of France, he was told,
was overwhelmed by the difficulties that naturally encompass every
government in its commencement. His declaration of the pacific
policy of the empire was but the unwilling avowal of his weakness,
and of his fears. The agitation of political parties, he believed, ruined
the country, though, since 1789, political intrigues, secret societies,
and conspiracies never were more powerless than at the moment we
speak of. The agents who thus instructed the Emperor of Russia
crowned those reports by depicting Louis Napoleon as apathetic,
because they saw him calm; as hesitating and timid, because they
saw him patient and moderate.
We have no doubt that the Emperor of Russia was led into similar
error with respect to this country. He was assured that it had become
selfish and apathetic from its unexampled prosperity; and that so
opulent and so sensual a nation would never expose itself, after so
long a peace, to the chances and the dangers of a long war, for the
sake of maintaining the integrity and independence of an empire
whose people preferred the Koran to the Bible. Their commercial
prudence, the love of ease engendered by opulence, the long period
of time that passed since the wars with the first Napoleon, the many
important interests which have grown up since then, religious
antipathy—everything, in fact—indisposed the English nation to
interfere with his designs in Turkey. But the presence in the
Government of a statesman, recently so ridiculed and insulted by
those who were now his colleagues, believed to be a warm admirer of
the Emperor of Russia, and known for his cold hatred of the
Emperor of the French, was considered the most fortunate
circumstance of all; it was, at any rate, a guarantee against any
favourable understanding with France or her ruler. Letters, said to be
from that statesman, addressed to one of the former ministers of
Louis Philippe, were read in one of the principal Russian saloons in
Paris, the most notorious of all for intrigues, and the resort of the
leaders of every anti-national party. These letters, asserted to be
genuine, are described as having alluded in terms of the greatest
contempt to the person, the character, and the intellect of Louis
Napoleon; and as containing declarations that, under no
circumstances whatever, could England act with France so long as its
present regime lasted. The scum of the Orleanist agency were sent
round to circulate the news, and despatches addressed to St
Petersburg repeated the same. The tone of a portion of the daily
press in England with reference to France seemed to confirm those
assurances, and to render the formation of a coalition against the
French Emperor, in which it was hoped England would join, by no
means a difficult nor an improbable task. The falsest of all these
calculations was unquestionably that which represented England as
labouring under an oppression of wealth, a plethora of opulence, of
which indifference, timidity, and inaction were the consequences. Yet
such is the description given of us to Russia by Orleanists, whose
incapacity and cowardice produced the overthrow of the dynasty of
July. The acquisition of wealth and power supposes the possession of
great energy of character; for those qualities we have been
distinguished above all other people. That we have not become
wearied or satiated, the events of each day that passes over our heads
prove; and whatever be the period at which we are destined to reach
the declining point, and which such scribblers as Ledru Rollin and
the like maintain we have attained, we ourselves believe that the fatal
moment is still far distant. We have shown energy without example,
since the time of the Romans, in making ourselves what we are; and
we are ready to let the world see that we know how to maintain the
power which was supposed to have enervated us, with more than
Roman courage. With admitted social and political evils—far less,
however, than any other nation on earth—we have not become
corrupt or effeminate. It is not true that the extraordinary
development of our public and private fortune has buried us in that
shameful indolence which made the Romans so easy a prey to the
barbarians. Prosperity has not made us forget or disregard our
rights. The wonderful development of our railway communications
and our steam navigation, the extension of our commerce, the
pacification of India, the colonisation of Africa, ought to have shown
the Emperor of Russia that we have not yet fallen from our high
estate in the political or moral world. The mighty fleets and the
gallant bands of warriors that are even now conveying to him our
answer to his insolent defiance, will show him the magnitude of his
error. Our courage and our activity, our resolution in council, and
our sternness in execution, are in proportion to the grandeur of the
interests we have to defend. Our decline, much less our fall, has not
yet commenced; and if any foreign or domestic friend has persuaded
Russia that we resemble the Romans in the latter days of their
empire, and that we are in a condition to fall a prey to the barbarians,
he is an idiot or a calumniator.
Nothing is now so clear as that the Emperor of Russia has been
most grossly deceived with respect to Turkey; but it is just to admit
that the error has been also shared by many who should know better.
Prince Menschikoff, during his short sojourn at Constantinople, had
only time to insult the Sultan and his government, but also time to
rouse a spirit of resentment and resistance. The backwardness of
Turkey in civilisation was taken as a proof of her weakness and her
deficiency in moral courage. But, with all her shortcomings, the old
Mussulman spirit still subsisted amid the ruins of her former glory.
It has been said that there are qualities which are effaced or
destroyed by refinement, but there are others which live without it,
though the occasion may have seldom occurred to call them forth.
Turkish patriotism was regarded as a byword, Turkish loyalty as a
mockery; Turkish courage was more than doubtful; and nothing
remained of the daring valour which, in other times, made
Christendom quail before the Crescent, except that vigour of faith
which once distinguished the children of the Prophet: and even that,
we were led to believe, had degenerated into a brutal and ignoble
fanaticism, capable of vulgar crime, but unequal to a single act of
heroism. The arrogant envoy of Russia rendered an essential service,
not to his imperial master, but to his intended victim. His insults
roused the dormant spirit of the Mussulman. The Ottoman army was
undisciplined—unprovided with the commonest necessaries; the
navy was but the melancholy remnant of Navarino; the Sultan’s
authority was weakened by internal abuses and disorders; his
territory dismembered by the separation of Greece, and by the all but
successful rebellion of Egypt. Those to whom he looked for aid or
protection against his colossal foe were long cold, if not hostile to
him; yet Turkey rose with a courage and a dignity which have
extorted applause, and won respect, even from those who were most
indisposed to her cause, politically and religiously. She summoned
her children about her; appealed, not to the relentless fanaticism of
their creed, but to their manlier and nobler instincts; and after
making every sacrifice, every concession consistent with self-respect,
to appease or disarm her unscrupulous and faithless enemy, who was
bent on her destruction, drew the sword in the cause of her
independence. Whilst still uncertain whether she was to maintain the
struggle alone and unsympathised with, against fearful odds, she
advanced to the contest with a bravery worthy of better times, and
with a success which has astonished her friends as well as foes. The
feelings which Prince Menschikoff believed he could most safely
outrage were those which quickened the nation into life and vigour.
The Emperor of Russia was astonished at a result so different from
what he was led to expect. The advices which had reached him from
his friends in London, Paris, Berlin, Vienna, and Constantinople,
were such as might have been true some twenty years ago, but were
false in 1853. France and England were said to be divided, and likely
to remain so as long as a Buonaparte ruled the destinies of the
former, and as long as Lord Aberdeen directed the administration of
the latter. France had become exhausted by revolution, discontented
with her new chief, demoralised, and rotten at the very heart;—no
remedy to restore her, till the Count de Chambord, or the Count de
Paris, was restored to the throne; and with England, satiated and
unwieldy with unwholesome prosperity, no desire remained, no
passion survived, but that of enjoying in undisturbed tranquillity
what she had hardly acquired. Count Orloff has learned something at
Vienna; but it does not appear that the lesson has much profited him
or his imperious master.
In these multiplied and intricate transactions, in which Russia was
alternately the deceived and the deceiver, there is one point in
particular to which we would direct the attention of our readers. We
allude to the claim made by the Porte to the intervention of the great
powers in its quarrel with Russia. It is a claim based on equity and on
international law, which it is impossible to dispute. Previous to 1841,
Turkey was hardly looked upon as forming part of the general
combination of European states in the settlement of any great
international question. Rightly or wrongly, the Turks were
considered less as forming an integral part of the European family of
nations, than as an agglomeration of various tribes of warriors,
bound together only by a common superstition and a common
fanaticism; not rooted in the soil they occupied, but merely
encamped on the outskirts of Christendom. The Treaties of 1841,
which facilitated to France the resumption of her place in Europe,
after her separation the previous year, also admitted Turkey to that
general political association. That privilege or right Turkey has not
forgotten in her hour of need, as we believe she would have done in
her hour of prosperity; and in her appeal to the world against the
pretensions of Russia, she summoned Austria, France, Prussia, and
Great Britain, in the name of those solemn obligations, to come to
her aid. She maintained that her participation in what is termed, in
diplomatic parlance, the Concerte Européen, was recognised; and
she showed, we think successfully, that henceforth all questions
affecting the independence and integrity of her territory should be
brought before the great tribunal of European states, and not left to
the judgment of a single and an interested power. The principle of
the right claimed by Turkey was admitted by the Cabinets of Vienna,
Berlin, Paris, and London; and that recognition is manifest in the
documents that have been made public. In the note addressed to the
Austrian Cabinet on the 31st December 1853, we find this
declaration:—“The multiplicity of the relations and the alliances of
the Sublime Porte and of the European States, giving to it, in every
respect, the right and the faculty of participating in the community
which binds these States to each other, and to the security which they
derive from them, the necessity will be felt of confirming and
completing in that sense the Treaty of 1841, and for that it reposes on
the friendly efforts of the allied Courts.” And the allied Courts, in
turn, declared, “that the Russian Government, which invaded the
territory of the Sultan, had placed itself in opposition with the
resolutions declared by the great powers of Europe in 1840 and 1841.
That, moreover, the spirit of the important transaction in which
Russia took part in 1841 with the other powers, and with Turkey
herself, is opposed to the pretension that the affairs of the East
should be treated otherwise than in common, and in the conferences
in which all these interests should be examined and discussed. And it
must be well understood that every such question must be treated by
five; and that it does not belong to one or to two cabinets to settle,
separately or apart, interests which may affect the whole of Europe.”
The allies of Turkey also added, “that the Treaty of 1841, in the
meaning of which all are this day agreed, is to serve as the basis of
operations. All the powers who have signed that treaty are qualified
to appeal to it. We present ourselves as the defenders of that treaty,
violated in its spirit, and as the supporters of the equilibrium of
Europe, menaced by the power which seemed, more than any other,
to have the pretension of constituting herself the guardian of it. The
cause for which we are armed is that of all.” That claim of Turkey to
form part of the European community is precisely the one to which
Russia is inexorably opposed. Its admission would destroy the
monopoly of interference and protection which the Czar wishes to
maintain over Turkey, and we need not therefore be surprised at the
stern refusals which the good offices of any other power have
invariably encountered at St Petersburg. Russia insisted throughout
that the question only regarded Russia and Turkey; it denied the
right of any one to interfere, except in advising Turkey to submit to
her dictates; and to the last she rejected all intervention or
mediation. It is true that intervention menaced the fundamental
principle on which the traditional policy of Russia is based; and the
day that the Treaty of 1841 forms part of the international law of
Europe, the designs of Russia on Turkey are at once arrested. Russia
will then have lost all exclusive rights; and all questions of public
interest affecting the Porte must be treated by all the states who have
affixed their signatures to that important instrument.
We are decidedly of opinion that the view taken by Turkey of the
rights created for her by this new state of things, is the correct one;
and we submit that the interpretation which gives the greatest effect
to the joint engagement of the four powers, is that which is most
conformable to the spirit and meaning of its framers. “The important
act of this Convention,” said M. Guizot in the Chamber of Peers, “is
to have included the Porte itself, the inviolability of the sovereign
rights of the Sultan, the repose of the Ottoman Empire, in the public
law of Europe. Therein is comprised the general recognition—the
recognition made in common, and officially declared—of the
inviolability of the sovereign rights of the Porte, and of the
consolidation of the Turkish Empire. It cannot be supposed that
France would have refused to facilitate by her adhesion the execution
of that act.” “The Turco-Egyptian question,” said the same minister
in the Chamber of deputies, “was settled—the question of
Constantinople remained. What is the object the policy of Europe has
in view for a long time past with reference to Constantinople? It is to
withdraw Constantinople from exclusive protection; to admit Turkey
into our European law; and to prevent her from becoming the
Portugal of Russia. Well, then, a step has been made towards that
end. It is true that the Porte has not been secured from ambition of
all kinds—from all the chances of the future; but, at all events, we
have an official instrument, signed by all the great powers of Europe,
which admits Turkey into the European law, which declares that it is
the intention of all the great powers to respect the inviolability of the
Sultan’s rights, and to consolidate the repose of the Ottoman
Empire.”
There is no doubt that Russia is deeply interested in the possession
of Constantinople. It is equally certain that, whenever she becomes
mistress of both shores of the Bosphorus, she will, in an incredibly
short time, add to her present pre-eminent military character that of
a first-rate commercial and maritime power. The populations that
would then acknowledge the supremacy of the Knout would be over
eighty millions; and the seventy millions of Christians professing the
Greek faith would bow their necks to the political and religious
autocrat. Russia would then indeed hold at her girdle the keys of the
Caspian Sea, the lake of Azof, the Black Sea, and the Mediterranean.
The possession of Syria and Egypt would before long follow, as a
matter of course, that of Turkey in Europe; and soon the fairest
regions in the world, the most fertile shores of that inland sea, would
fall under her rule. A single glance at the map will enable us to
comprehend the magnificence, the vast extent, of such an
acquisition; and the mind may dwell with wonder on the immensity
of the new Russian Empire in Europe and Asia, and anticipate the
supremacy she would gain by the conquest of Constantinople, which
opens to her a path to the very heart of civilised Europe. That Russia
should make gigantic efforts, and risk, as she is now risking, her rank
as a first-rate Power, if not her existence, to attain such an object, is
not astonishing. The fair capital that stands on the Bosphorus is the
guarantee of the empire of the world. It is more than the ambition of
Alexander, of Charlemagne, or of Napoleon, ever dreamed the
realisation of; and if treachery or violence ever gives it to Russia, the
irresistible and universal domination of Rome over the rest of the
world, after the fall of Carthage, alone furnishes an example of what
Russia would then become.
Russia has, by the tolerance or apathy of Europe, been singularly
favoured since the seventeenth century; and she whose name was not
even mentioned in the Treaty of Westphalia, which defined the limits
of the great European states, has risen to gigantic proportions since
then. She has invariably availed herself, as she is now ready to do, of
the dissensions of the Western kingdoms; she has absorbed
provinces and nations of various tongues, religions, and races; and
has opened her way, through the territories of her neighbours, to the
shores of two seas. Her hand it was that put an end to the existence
of Poland. It was she that paralysed Sweden and Denmark; and it is
by her that Persia and Turkey have been pushed on to their ruin. The
history of her crimes in Poland is the same as that of her plunder in
Turkey, Georgia, and Persia; and the partition of the ancient
northern kingdom is now to be repeated with the Ottoman Empire.
The means she employs are ever the same;—menaces and caresses by
turns;—attempts at exclusive intervention;—a slow but steady system
of dismemberment;—pretensions and claims, as impudently
advanced as they are unfounded; then apparently withdrawn,
postponed, placed in abeyance, seemingly forgotten, but never finally
abandoned; revived with hypocritical humility, or with arrogance,
according to circumstances; pretexts of quarrel of the most
imaginary and untenable kind; intimidation mingled with seduction.
Nothing is too bold, too base for her selfishness. Her princes and
nobles are spies; her princesses—worse. No profligacy is too gross,
no crime is too enormous, that advances by one inch the influence of
“Holy Russia.” War is undertaken for no other object than to arrive
at conventions ruinous to the conquered. Such is the hereditary
policy of Russia; such it has been since she first assumed a standing
in Europe; and we say it to our shame, that her unexampled success
is in great part owing to the selfishness of some, the exaggerated
fears of others, and the indifference and apathy of all the states of
Europe. If England and France had but pronounced a veto in 1774,
Poland might, with a reformed constitution, and an improved
administration, still be an independent kingdom, and stand the
barrier between the barbarism of the north and the civilisation of the
west. If the Western Powers had directed their attention a little more
frequently, and more earnestly to Turkey, the events against which
we are now preparing might not have taken place. Even now, it is not
too late; and we firmly believe that it is in the power, as we have little
doubt it is the desire, of Europe, to arrest for many years the
aggressive policy of Russia.
We have heard one argument advanced against our interference to
save Turkey from Russia, and which seems to have made a certain
impression in some quarters. We think the argument to be more
specious than real; and the only reason we notice it here is, because it
has been dwelt upon by persons whose opinions are in other respects
entitled to consideration. We are told that it is a shame and a scandal
for a civilised and religious nation to go to war in support of a
barbarous and unbelieving Government. If such an argument mean
anything, it must mean that England is to have no ally but such as
can boast of equal civilisation, and profess the same faith as
ourselves. We deny that we go to war, and in support of Turkey, in
order to insure the supremacy of the Koran over the Bible, of the
Crescent over the Cross, of barbarism over civilisation. We take the
part of Turkey, not on religious grounds, but on political; to prevent
the extension of Russia in those parts of Europe and Asia where her
power would seriously endanger the vital interests of Western
Europe; to maintain what is termed the balance of Europe; or, in
other words, to prevent any one Power from growing to such a
colossal size as that all the others would be at her mercy. We do not
go to war to continue Mussulman barbarism, or to perpetuate the
despotism under which the Christian populations have groaned. The
conditions on which France and England afford succour to the Sultan
are, that the reform long since commenced by Sultan Mahmoud, and
continued by Abdul Medjid, shall be still further developed; and that
the Christian subjects of the Porte, whose condition has materially
improved, shall be placed on an equality with the Mussulmans. As
well might it be said that our wars in Spain had for their object the
protection of the Roman Catholic religion, the consolidation of the
influence of the Pope, the re-establishment of the Inquisition, or the
perpetuation of the stupid despotism of Ferdinand. We entered on
the Peninsular war, not for such objects, but for reasons similar to
those which now lead us to the East;—to rescue the Spanish territory
from the grasp of a usurper, from the power of a conqueror whose
ambition of universal rule was not less than that of Nicholas; to
prevent the whole of Europe from falling under the dominion of a
single potentate. In this country we denounce the doctrines of the
Church of Rome as contrary to Scripture, and we, a Protestant
Government, employed its armies in defence of a nation whose
principle has been, and still is, intolerance of all other creeds but its
own, and against a Government which, whatever may have been its
faults, had not, at all events, religious intolerance among them. In no
country is the Roman Catholic religion made to assume a more
odious form than in Spain. We are told that the Turks speak of
Christians as “dogs;” but, in Christian Spain, English Protestants are
actually treated as dogs, or worse. We have seen, and this within a
very few years, those who fought, and bled, and died in the cause of
Spanish independence, flung, like offal, into a hole, or left to rot on
the sea coast below high-water mark. We have, within the last few
months, witnessed the tedious negotiations carried on between our
Minister at Madrid and the Government in whose cause our blood
and treasures have been spent with profusion, to obtain a secluded
spot of earth wherein the bones of those of our countrymen, who still
labour to introduce civilisation into that country, may be sheltered
from pollution; and we have no cause to rejoice at its humiliating
conclusion. When we are told of Turkish bigotry and intolerance, we
would point to Madrid, to Naples, and to Tuscany. Turkish honour
and Turkish fidelity to engagements will not suffer by a comparison
with the Government of her most Catholic Majesty, as we presume
those Englishmen who have had anything to do with it will be ready
to admit. We are not of opinion that the barbarism of the Turks is
greater than that which may be found in many parts of the Spanish
peninsula; and those who have travelled into the interior of both
countries may bear witness to the fact that her Catholic Majesty’s
subjects, with the exception of the large towns, cannot be surpassed
by any others in ignorance, sloth, and bigotry. Corrupt as the Turkish
Government may have been, and badly administered as the country
unquestionably is, we doubt whether the general run of Spanish
statesmen have exhibited much more probity, integrity, and talent in
government, with all the advantages of our example; and, in the
matter of private morals, we think we could point out Spanish
sovereigns who, with all their piety and attachment to Catholicism,
have not much to boast over Sultan Abdul Medjid. We are not of
opinion that, as respects mere civilisation, the Russian serfs are
superior to the Turks. We have no evidence that Russia has made any
improvement within the recollection of the present generation; while
it is undeniable that, within the same space of time, Turkey had
made, and is still making, material progress in its administration.
Since the time of Mahmoud, Turkey—though, of course, still far
behind France and England—has effected immense ameliorations in
all matters connected with internal navigation, with her military and
naval establishments, and her political and judicial administration;
and, from the great improvement that has taken place in the
condition of her Christian populations, we are confident that, before
long, she will realise the wish of Mahmoud, and those populations
will be placed on a footing of political equality with the Mussulmans.
We doubt whether all these things can be stated of Russia.
The Grand-duke Michael is said to have predicted the
dismemberment of the Russian Empire soon after the death of the
present autocrat. Whatever be the claims of that prince to the
character of a prophet, it is evident that Russia is now approaching a
more important crisis. Russia will give way, or she will not. If the
former, her prestige is gone, and the pettiest Continental kingdom
may regard her with indifference. If the latter, a more terrible fate
may await her, for she can scarcely resist all that is powerful in
Europe combined against her. Russia has been to Europe, for the last
forty years, what a ball remaining in an old wound is to the limb of a
veteran. Every change of temperature, the heat of summer, the cold
of winter, produces uneasiness and pain. The ball must now be
extracted; the wound must now be entirely closed up, that we may be
all at rest.
Since the preceding pages were written, a “Confidential
correspondence” has been brought to light, which no longer leaves
any mystery in this once incomprehensible question. Our readers
will find these important documents, and the indefensible conduct of
the Ministry in the matter, fully discussed in the concluding article of
this Number.
LIFE IN THE SAHARA.
Tired of poetical criticism, in which we last month so freely

indulged, and turning with satisfaction from the political
disquisitions now going through the press for the benefit of our
sorely-perplexed countrymen, we feel disposed, cutting both poetry
and politics, fairly to fly our shores, and recreate ourselves and
readers in some less troubled quarter of the earth. Among the host of
new books on our table, redolent of Cossack and Turk, Cross and
Crescent, and here and there interspersed with cabalistic-looking
titles, which, we are requested to believe, signify the “Doom of
Turkey,” or the “Drying up of the Euphrates”—lo, there peeps forth
one of a more pacific hue. There, lustrous on its boards, rises the
feathery palm-tree of the Desert,—the Arab tent,—the camel; and
what an emblem of peace is that cross-legged Oriental, smoking his
long pipe, imperturbable as a statue! Sedit æternumque sedebit. We
open the book, and, amidst the intricacies of a very long title, catch
the piquant words—“Wanderings in the African Sahara.”[10] How we
feel the breezes of the Desert come around us!—the freedom,—the
expanse,—the wild novelty of the scene;—the heaving motion of the
camel beneath us,—the flashing spears and pennons of the escort, as
they whirl in mimic warfare around. Away into the Desert! with a sea
of rigid white sand beneath, and a twin sea of glowing light above!
On, over the waste, till the glare of day is done, and the cool breeze
comes forth, and all the stars of night,—and we kiss our hand to the
moon “walking in brightness,” and say, with Southey,
“How beautiful is night!
A dewy freshness fills the silent air;
No mist obscures, nor cloud, nor speck, nor stain,
Breaks the serene of heaven;
In full-orbed glory yonder Moon divine
Rolls through the dark-blue depths.
Beneath her steady ray
The desert-circle spreads,
Like the round ocean, girdled by the sky!
How beautiful is night!”
What mystery hangs over this last-born of continents! whose

plains are sea-beds, at whose vast upheaval the waters of ocean must
have rushed furiously in all directions to regain their level. A land of
mystery, from the days of Herodotus until now. How we long to join
those yearly caravans, which, after leaving behind them the whole
northern region of the coast, travel for sixty days southwards
through the burning Sahara,—reaching springs but once a-week,—
crossing alternately now mountain-ridges, now seas of sand; until,
passing from oasis to oasis, they at length penetrate into the region
of Soudaan,—the heart of Africa, the death-place of Clapperton, and
Richardson, and Overweg,—and behold the great central lake of
Tchad, the most inaccessible point on the globe, yet to within a few
miles of whose shores the dying energies of Clapperton brought a
boat,—whose waters have been navigated by his European comrade,
and on whose bosom, perchance, that bark still floats, with the flag of
England flying from its mast!
Such were the quick musings of the moment of imaginative
pleasure which elapsed, as we cut open preface and contents, and
plunged into the book itself. In a trice, the argument of the book is
plain to us. After a residence of several years on the shores of North
Africa—during which time he seems to have mastered the various
dialects of the Arab tribes, and of course studied their manners—Mr
Davis, the reverend author, catches sight of an excellent opportunity
for visiting the interior. “Sidy Mohammed Bey,” he says, “the heir-
apparent of the throne of Tunis,—a prince possessed of excellent
qualities, among which extreme kindness and affability are not the
least prominent,—was on the point of making a journey into the
interior, in order to regulate some public affairs; and, upon
application, he very kindly took me under his immediate protection.”
On the sixth day after starting, they came to a good deal of broken
country,—traversed several dry beds of rivers,—and crossed a
number of rugged heights, rent into strange shapes. Marching
through an opening in one of these minor ridges, they passed at once
from a beautiful plain into the wild and ragged outskirts of the great
chain of Gebel Waslaat, celebrated for the warlike character of its
ancient inhabitants. “At a little distance,” says Mr Davis, “these
famous and romantic heights have a most lovely appearance,
resembling the vineyards of Spain and of the south of France;” but
on a nearer approach, he found—as on many other occasions during
the expedition—that it was only distance that lent to them their
enchanting look. The Arabs of the coast look upon this region as
perhaps the blackest spot in all creation; and you may as well call one
of them a devil as a Waslaati. They relate that this part was at one
time inhabited by a very wicked people, and that the Pharaoh under
whom the Israelites were in bondage, and who received such signal
chastisement, was a native of these mountains. The Mohammedan
doctors go still further, and assert that it was upon this Gebel
Waslaat that Eblis (Satan) was hurled down, after his expulsion from
the regions of light and happiness; and that it was in these
mountains that he took up his first earthly abode.
Leaving these ill-omened mountains to the west, they journeyed
south-eastwards, for two days, through a plain, which, says Mr
Davis, “for this part of the world, must be pronounced a luxuriant
one.” It is pretty well cultivated, and is watered by a river which has
its source in the Waslaat mountains. They then encamped for a
couple of days in the vicinity of Cairwan, the “city of saints.” “At a
short distance,” he says, “this, like every other Mohammedan city of
any note, has a fine appearance, but as one approaches, its beauty
vanishes. Crooked and filthy streets, ruined and dilapidated houses,
wretched shops and miserable hovels, are too glaring not to attract
one’s attention.” The city is surrounded by a wall in pretty good
condition, and has a garrison of regular as well as of irregular troops.
Outside are large cisterns, supplementing the reservoirs with which
the houses within are furnished for collecting rain-water; and, still
more remarkable, though much less useful, the tomb wherein repose
the holy remains of Saint Shaab, “the Prophet’s barber.”
After a two days’ halt, they left behind them the plain of Cairwan,
and began to approach the borders of the Sahara. On the day after
starting, the Prince’s party was met by the “noble and highly-
favoured” tribe of Arabs, the Dreeds (who are allowed to sit in
presence of a prince, whilst every other Arab is obliged to stand),
headed by their kaid or governor, Smeeda Ben Azooz. “Smeeda

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AACN Core Curriculum for Progressive

and Critical Care Nursing, 8e (May 19,

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AACN CORE CURRICULUM FOR PROGRESSIVE  ISBN: 978-0-323-77808-4

Copyright © 2023 by Elsevier, Inc. All rights reserved.

Executive Content Strategist: Lee Henderson

Nicole Brumfield, DNP, APRN, FNP-BC, AG-ACNP-BC

Deborah Chapa, PhD, ACNP-BC, FAANP, ACHPN

Jennifer MacDermott, MS, RN, ACNS-BC, NP-C, CCRN

Patricia Radovich, PhD, CNS, FCCM

Angie Atwood, PhD, RN

Michele Beatty Bachmann, MSN, RN

Beverly L. Banks, BSN, MSN, RN

Debra J. Behr, DNP, RN, CCRN-K

Collin Bowman-Woodall, MSN, RN

Mary Ann “Cammy” Christie, APRN, MSN, CCRN, CMC-CSC, PCCN

Judy E. Davidson, DNP, RN, MCCM, FAAN

Tina Deatherage, DNP, RN, CCNS, CCRN, CNRN, NEA-BC

Christina Flint, MSN, MBA, RN

Matthew J. Fox, MSN, RN-BC

Keble Frazer, BSN, RN-BC, CCRN, PCCN

Charles R. Gold, BSN, RN, CCRN

Ami Grek, DNP, APRN, ACNP-BC

Christopher Guelbert, DNP, RN, CCRN, CNML

Stephanie A. Gustman, BSN, MSN, DNP, RN

Christian Guzman, MS, CCRN, ACNPC-AG, APRN

Jillian Hamel, MS, RN, ACNP-BC

Sonya Renae Hardin, PhD, MBA/MHA, CCRN, ACNS-BC, NP-C, FAAN

Kiersten Henry, DNP, ACNP-BC, CCNS, CCRN-CMC

Cheryl Holsworth, MSA, RN, CBN, CMSRN

Robert C. Ingram, BSN, MSN, MHA, DNPc, RN, CEN

Tonia Kennedy, MSN, EdD, RN-BC, CCRN-K

Sara Knippa, MS, RN, CCRN, PCCN, ACCNS-AG

Marianna LeCron Presley, MSN, RN, CCRN

KellyAnne Lee, MSN, MBA, RN, CCRN

Tanaya C. Lindstrom, MSN, RN, CCRN, CNL

Yvette Lowery, MSN/Ed, DNP, FNP-c, CCRN, CEN, PCCN

Karen A. Matos, MSN, RN, CCRN

Paige McCraney, DNP, APRN

Denise M. McEnroe-Petitte, AS, BSN, MSN, PhD, RN

Katina M. Meyer, BSN, RN

Samantha Palmer Noah, MSN, APRN, FNP-BC, AGACNP-BC

DaiWai M. Olson, PhD, RN, CCRN, FNCS

Sarah Peacock, DNP, APRN, ACNP-BC

Deidra Pennington, MSN, RN

Ruthie Robinson, PhD, RN, CNS, FAEN, CEN, NEA-BC

Emily Rogers, DNP, AGACNP-BC, CCRN, APRN

Janet Czermak Russell, DNP, RN, APN-BC

Peter D. Smith, BA, MSN, RN

Ashley N. Thompson, DNP, AGACNP-BC

Tonja M. Hartjes, DNP, APRN, CNS, CCRN, CNEcl, FAANP

AACN Synergy Model for Patient Care (AACN, 2020a,b,c) 5

Healthy Work Environment Standards (AACN, 2016)17

Ethical Clinical Practice24

Chapter 2 Psychosocial Aspects of Critical Care38

PART II  ritical Care of Patients with Issues Affecting Specific Body

Specific Patient Health Problems 136

Chapter 4 Cardiovascular System 176

Specific Patient Health Problems 235

Non—ST Elevation Myocardial Infarction (See Acute Coronary Syndrome

Chapter 5 Neurologic System 354

Specific Patient Health Problems 417

AACN CORE CURRICULUM FOR PROGRESSIVE ISBN: 978-0-323-77808-4

AACN Synergy Model for Patient Care (AACN, 2020a,b,c) 5

Healthy Work Environment Standards (AACN, 2016)17

Ethical Clinical Practice24

Chapter 2 Psychosocial Aspects of Critical Care38

PART II ritical Care of Patients with Issues Affecting Specific Body

Specific Patient Health Problems 136

Chapter 4 Cardiovascular System 176

Specific Patient Health Problems 235

Chapter 5 Neurologic System 354

Specific Patient Health Problems 417

Chapter 6 Renal System490

Diagnostic Studies 507

Specific Patient Health Problems520

Chapter 7 Endocrine System564

Chapter 8 Hematologic and Immunologic Systems 593

Specific Patient Health Problems 604

Chapter 9 Gastrointestinal System 631

Specific Patient Health Problems 652

Chapter 11 Multisystem Trauma 706

Thoracic Trauma: Pulmonary and Cardiac

Chapter 14 Toxin Exposure 776

Care of the Bariatric Surgery Patient 806

Related Bariatric Care Issues807

Chapter 16 Older Adult Patients809

Age-Related Changes in Medication Action and Clinical Implications809

The Four Ms of Age-Friendly Health Care814

Chapter 17 High-Risk Obstetric Patients820

Specific Patient Health Problems823

Chapter 18 Patient Transport836

Indications for Transport837

Modes of Interfacility Transport838

Risks and Stresses of Transport839

Overriding Priorities in Patient Transport841

Preparation for Transport841

Patient Care During Transport844

Legal and Ethical Issues Related to Transport845

Specific Patient Health Problems855

Specific Clinical Problems Related to Pain Therapy885

Specific Patient Health Problems886

Chapter 21 Palliative and End-of-Life Care888

Chapter 22 Perioperative Care898

Specific Patient Health Problems917