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Contributors and Reviewers

CONTRIBUTORS Predrag Miskin, DrHS, MScN, RN, PHN, DMSRN

Nursing Faculty
Karen V. Anderson, MSN, RN Biological and Health Sciences
Associate Dean of Nursing De Anza College
Nursing Department Cupertino, California
Kaplan College, San Diego Adjunct Assistant Professor
San Diego, California School of Nursing
8 Communication and the Nurse-Patient Relationship Samuel Merritt University
17 Infection Prevention and Control in the Hospital and Oakland, California
Home 14 Cultural and Spiritual Aspects of Patient Care
34 Administering Oral, Topical, and Inhalant Medications 15 Loss, Grief, and End-of-Life Care
36 Administering Intravenous Solutions and Medications
39 Promoting Musculoskeletal Function Susan M. Schmitz, RN, BSN, PHN
Associate Faculty
Shelley Eckvahl, BSN, MSN Health Occupations Department
Professor Mission College
Nursing Santa Clara, California
Chaffey Community College Part-Time Faculty
Rancho Cucamonga, California Health Technology Department
3 Legal and Ethical Aspects of Nursing De Anza College
5 Assessment, Nursing Diagnosis, and Planning Cupertino, California
9 Patient Education and Health Promotion American Heart Association ACLS, BLS, and First Aid
16 Infection Prevention and Control: Protective Mechanisms Instructor
and Asepsis Nurse Education Workshops Inc
San Jose, California
Louise S. Frantz, MHA, Ed, BSN, RN 19 Assisting With Hygiene, Personal Care, Skin Care, and
Practical Nursing Program Coordinator the Prevention of Pressure Injuries
Continuing Education 20 Patient Environment and Safety
Penn State Berks 22 Assessing Health Status
Reading, Pennsylvania 23 Admitting, Transferring, and Discharging Patients
26 Concepts of Basic Nutrition and Cultural 28 Assisting with Respiration and Oxygen Delivery
Considerations 29 Promoting Urinary Elimination
27 Nutritional Therapy and Assisted Feeding 30 Promoting Bowel Elimination
31 Pain, Comfort, and Sleep
Garry Johnson, DHSc, RN, CCRN, CMSRN 32 Complementary and Alternative Therapies
Nursing Professor 37 Care of the Surgical Patient
Evergreen Valley College
San Jose, California Gerald “Jerry” Thompson, MSN, RN, CNE
Adjunct Nursing Professor Assistant Professor
Samuel Merritt University Undergraduate Nursing
San Mateo, California Samuel Merritt University
Mission College Oakland, California
Santa Clara, California 7 Documentation of Nursing Care
18 Safely Lifting, Moving, and Positioning Patients 21 Measuring Vital Signs

vi
 CONTRIBUTORS AND REVIEWERS vii

REVIEWERS Joanne Heck, RN, MSN

LPN Instructor
Sherri L. Andrews, RN, MSN Parkland College
Faculty Health Professions
Bedford County Public Schools Champaign, Illinois
Bedford County School of Practical Nurses
Bedford Science and Technology Center Kathleen Garrubba Hopkins, PhD, MSIE, RN
Bedford, Virginia NINR/NIH Fellow
University of Pittsburgh
Sharyn Boyle, MSN, RN-BC School of Nursing
LPN Instructor Pittsburgh, Pennsylvania
Passaic County Technical Institute
LPN Program Dawn Johnson, MSN, RN, Ed
Wayne, New Jersey Director of Practical Nursing Program
Great Lakes Institute of Technology
Fleurdeliz Cuyco, BS Nursing
Compliance Director/Instructor Erie, Pennsylvania
Preferred College of Nursing
Los Angeles, California Russlyn A. St. John, RN, MSN
Professor Emeritus
Natalie O. DeLeonardis, MSN, RN St. Charles Community College
Coordinator, North Campus Outreach Practical Nursing & Allied Health
Nursing Program Cottleville, Missouri
Pennsylvania College of Technology
Williamsport, Pennsylvania Kelly Stone, RN, BSN
Coordinator
Louise S. Frantz, MHA, Ed, BSN, RN Practical Nursing Program
Coordinator Practical Nursing Program University of Arkansas Community College Batesville
Penn State University—Berks Campus Batesville, Arkansas
Continuing Education
Reading, Pennsylvania Judith M. Thompson, RN, MN, CMSRN
Nursing Faculty
Chasity Girvin, BSN, MSN, RN Richmond Community College
Nursing Faculty/Sim Lab Coordinator Hamlet, North Carolina
Fayette County Career & Technical Institute
LPN Program
Uniontown, Pennsylvania
LPN Advisory Board
Tawne D. Blackful, RN, MSN, MEd
Supervisor of Health Services and School Nurse
Lawrence Hall Youth Services
Chicago, Illinois
Barbara Carrig, BSN, MSN, APN
LPN Nurse Program Coordinator
Academic/Clinical Instructor, Passaic County
Technical Institute
Wayne, New Jersey
Dolores Cotton, MSN, RN
Practical Nursing Coordinator
Meridian Technology Center
Stillwater, Oklahoma
Laurie F. Fontenot, BSN, RN
Department Head, Health Services Division
Acadiana Technical College—C.B. Coreil Campus
Ville Platte, Louisiana
Shelly R. Hovis, RN, MS
Director, Practical Nursing
Kiamichi Technology Centers
Antlers, Oklahoma
Patty Knecht, MSN, RN
Director of Practical Nursing
Center for Arts and Technology—Brandywine Campus
Coatesville, Pennsylvania
Hana Malik, MSN, FNP-BC
Family Nurse Practitioner
Take Care Health Systems
Villa Park, Illinois
Barb McFall-Ratliff, MSN, RN
Director of Nursing, Program of Practical Nurse
Education
Butler Technology and Career Development Schools
Hamilton, Ohio
viii
Toni L.E. Pritchard, BSN, MSN, EdD
Allied Health Professor, Practical Nursing Program
Central Louisiana Technical College—Lamar Salter
Campus
Leesville, Louisiana
Pamela Reyes, RN, BSN, MSN
Assistant Director
Nursing, Porter and Chester Institute
Rocky Hill, Connecticut
Barbra Robins, BSN, MSN
Program Director
Leads School of Technology
New Castle, Delaware
Faye Silverman, RN, MSN/Ed, PHN, WOCN
Director of Nursing
Kaplan College
North Hollywood, California
Russlyn A. St. John, RN, MSN
Professor and Coordinator, Practical Nursing
Practical Nursing Department, St. Charles Community
College
Cottleville, Missouri
Fleur de Liza S. Tobias-Cuyco, BSc, CPhT
Dean, Director of Student Affairs, and Instructor
Preferred College of Nursing
Los Angeles, California
To the Instructor
DeWit’s Fundamental Concepts and Skills for Nursing, ifth
edition, written especially for licensed practical nurse/
licensed vocational nurse (LPN/LVN) students, incor-
porates aspects of nursing in all of the major settings in
which LPN/LVNs are employed: hospitals, long-term
care facilities, clinics, medical ofices, home care agen-
cies, and surgery centers. This edition further empha-
sizes the importance of evidence-based practice and
the use of best practices.
This text teaches all the basic concepts and funda-
mental skills that an LPN/LVN needs in current prac-
tice. The material is presented from simple to complex,
with clarity and conciseness of language, making the
fundamental concepts and skills content readily com-
prehended by beginning nursing students. Because
there are so many students with English as their sec-
ond language entering nursing, this book has been re-
viewed and edited by an English-as-a-second-language
specialist to make the language as clear as possible.
As the role of the LPN/LVN expands, there is an
even greater need for a thorough knowledge of the
nursing process and problem solving. The nursing
process is the underlying theme of the text and is in-
terwoven with these six threads: (1) focus on the pa-
tient as a consumer of health care with psychosocial
as well as physical needs; (2) critical thinking as a
tool for learning, problem solving, and developing
clinical judgment; (3) communication as an essential
tool for the art and practice of nursing; (4) collabo-
ration with other health care workers and the use of
management and supervision to provide coordinated,
cost-effective patient care; (5) patient education for the
maintenance of wellness and promotion of self-care;
and (6) integration of cultural sensitivity and cultural
competence into patient care.
Because of the difference in state laws, LPN/LVNs
in some states may be certiied to perform a variety
of tasks related to intravenous (IV) luid therapy, but
in other states IV therapy is not within the scope of
practice. We do include IV therapy because so many
schools teach a separate short course on it for IV cer-
tiication for their students. Consult your state nurse
practice act for more information.
ORGANIZATION OF THE TEXT
CONTENT
The text is divided into the following nine units: I, In-
troduction to Nursing and the Health Care System; II,
The Nursing Process; III, Communication in Nursing;
IV, Developmental, Psychosocial, and Cultural Con-
siderations; V, Basic Nursing Skills; VI, Meeting Basic
Physiologic Needs; VII, Medication Administration;
VIII, Care of the Surgical and Immobile Patient; IX,
Caring for the Elderly.
In this ifth edition, we are pleased to include the
following new content:
• Updated 2016 NPUAP Pressure Injury Stages
• Greater emphasis on QSEN (Quality and Safety Ed-
ucation for Nurses) with numerous boxed features
throughout the text
• List of Giddens’ Concepts presented at the begin-
ning of each chapter
• The most current CPR guidelines from the Ameri-
can Heart Association
• The 2015 United States Department of Agriculture
dietary guidelines
• Updated Joint Commission Pain Standards
• Greater emphasis on electronic MAR (eMAR), com-
puterized order entry (CPOE), and computer docu-
mentation of medication administration
• Updated American Heart Association diet and life-
style recommendations
The text emphasizes the following key content areas
and major concepts:
• Evidence-based nursing and best practices
• Updated isolation information from the Centers for
Disease Control and Prevention (CDC)
• Current immunization guidelines
• Ethnopharmacy
• Health care delivery, collaborative care, and chang-
ing and expanding role of the LPN/LVN
• Concepts of the nursing process and their applica-
tion to clinical situations
• Nurse–patient and family communication
• Professional communication
• Management, supervision, and delegation
• Health promotion and patient education
• Healthy People 2020 Objectives and National Patient
Safety Goals
• Growth and development from infancy through
adulthood, with special attention to the older adult
• Cultural sensitivity in nursing care
• Full chapter on loss, grief, end-of-life care, and pal-
liative care
• Basic nursing skills, including current informa-
tion about infection control in the health care set-
ting and home, dangers of drug-resistant infections,
ix
x TO THE INSTRUCTOR
prevention of pressure injuries, patient safety, and
assessment of health status
• Concepts and skills needed to meet basic physio-
logic needs
• Complete unit on medication knowledge and ad-
ministration, with a section on blood product
administration
• A chapter on the administration of intravenous lu-
ids and medications
• Care of surgical patients; care of immobile patients,
including those needing care of wounds and pres-
sure injuries; promotion of musculoskeletal function
• Physiologic and psychosocial care of the older adult
SPECIAL FEATURES
The following pedagogic features help students to un-
derstand and apply the chapter content:
• Overview of Structure and Function: In chapters in
which an understanding of anatomy and physiol-
ogy is necessary to comprehend the chapter content,
a brief review of the body system directly precedes
the main text of the chapter.
• Application of the Nursing Process: After the ba-
sic concepts of nursing and the nursing process are
introduced in Unit Two, the nursing process is inte-
grated in succeeding chapters.
• Special features within the text, including Clinical
Cues, Complementary & Alternative Therapies,
Cultural Considerations, Life-Span Consider-
ations, Focused Assessment, Health Promotion,
Home Care Considerations, Legal and Ethical
Considerations, Patient Education, QSEN Consid-
erations, Safety Alert, and Think Critically boxes,
enhance student learning and retention. More infor-
mation on each of these boxes is provided on pp.
xii-xiii.
• Concept Maps are visualizations of processes that
help students to make sense of information that is
typically more dificult to learn, and they are plenti-
ful throughout the text.
• NCLEX-PN Examination–Style Review Questions
at the end of each chapter include multiple-choice
and alternate-format questions to help students to
familiarize themselves with the format and prepare
for the examination.
• Nursing Care Plans: These illustrate each step of
the nursing process. Each nursing diagnosis is sup-
ported by the accompanying assessment data, and
Critical Thinking Questions are provided at the end
of each care plan. The nursing care plan has been
chosen as the focus for care planning because it is
such an integral part of teaching the nursing pro-
cess. Answers to Critical Thinking Questions in the
Nursing Care Plans are provided on the Evolve website.
• Skills: Seventy-ive of the major skills that require
mastery in most LPN/LVN programs are presented
with full-color photographs in a step-by-step for-
mat that emphasizes use of the nursing process and
includes rationales for each step, as well as Critical
Thinking Questions at the end of each skill. Per-
formance Checklists for all skills are located in the
Student Learning Guide. Answers to Critical Thinking
Questions in these Skills are provided in the Instructor
Resources on the Evolve website.
• Steps: Steps are shorter versions of skills. These 37
other procedures that nurses are expected to per-
form are presented step by step with rationales. Per-
formance Checklists for all steps are found on the Evolve
website.
• Appendixes: Appendix A contains the Standard
Steps protocol for the performance of each Skill and
Step. Appendix B presents the NFLPN Nursing Prac-
tice Standards for the Licensed Practical/Vocational
Nurse. Appendix C provides the ANA Code of Eth-
ics. Appendix D contains the CDC Standard Precau-
tions for the care of all patients. Appendix E contains
a table of the basic common laboratory test values.
Appendix F contains a listing of the NANDA deini-
tions used in this text.
• Bolded text throughout the narrative emphasizes
key concepts and practice.
LPN THREADS
The ifth edition of deWit’s Fundamental Concepts and
Skills for Nursing shares some feature and design ele-
ments with other Elsevier LPN/LVN textbooks. The
purpose of these LPN Threads is to make it easier for
students and instructors to use the variety of books
required by the relatively brief and demanding LPN/
LVN curriculum. The following features are included
in the LPN Threads:
• A reading level evaluation is performed on every
manuscript chapter during the book’s development
to increase the consistency among chapters and en-
sure the text is easy to understand.
• The full-color design, cover, photos, and illustrations
are visually appealing and pedagogically useful.
• Objectives (numbered) begin each chapter and pro-
vide a framework for content and are especially im-
portant in providing the structure for the TEACH
Lesson Plans for the textbook.
• Key Terms with phonetic pronunciations and page
number references are listed at the beginning of
each chapter. Key terms appear in color in the chap-
ter and are deined briely, with full deinitions in
the Glossary. The goal is to help the student reader
with limited proiciency in English to develop a
greater command of the pronunciation of scientiic
and nonscientiic English terminology.
• A wide variety of special features relate to critical
thinking, clinical practice, health promotion, safety,
patient education, complementary and alternative
therapies, communication, home health care, del-
egation and assignment, and more. Refer to the To
the Student section of this introduction on pp. xii-
xiii for descriptions.

• Critical Thinking Questions presented at the ends
of chapters and with Nursing Care Plans give stu-
dents opportunities to practice critical thinking
and clinical decision-making skills with realistic
patient scenarios. Answers are provided on the Evolve
website.
• Key Points at the end of each chapter correlate
to the objectives and serve as a useful chapter
review.
• A full suite of Instructor Resources is available,
including TEACH Lesson Plans and PowerPoint
Slides, Test Bank, Image Collection, Open-Book
Quizzes, and Answer Keys.
• In addition to consistent content, design, and sup-
port resources, these textbooks beneit from the ad-
vice and input of the Elsevier LPN/LVN Advisory
Board (see p. viii).
TEACHING AND LEARNING PACKAGE
We provide a rich, abundant collection of supplemen-
tal resources for both instructors and students.
FOR THE INSTRUCTOR
• ExamView Test Bank contains more than 1300
NCLEX-PN Examination–Style Questions, includ-
ing both multiple-choice and alternate-format
questions.
• TEACH Lesson Plans, based on textbook chap-
ter learning objectives, provide a roadmap to link
and integrate all parts of the educational package.
These concise and straightforward lesson plans can
be modiied or combined to meet scheduling and
teaching needs.
• PowerPoint Presentation provides more than 1500
slides including text and images.
• Open-Book Quizzes for each chapter in the text-
book vary instructor testing options.
• Image Collection includes illustrations and photo-
graphs from the book.
• Answer Keys to the Open Book Quizzes and to the
Study Guide activities and exercises are included.
FOR THE STUDENT
• Study Guide contains various types of questions
and activities, including Terminology; Short Answer;
Completion; Multiple Choice NCLEX-PN Examination
Review Questions; Application of the Nursing Process;
TO THE INSTRUCTOR xi
Priority Setting; Identiication; Review of Structure and
Function; Critical Thinking Activities; Clinical Activi-
ties; and Steps Toward Better Communication Activities.
The activities are designed to (1) reinforce material
in the text chapter; (2) provide practice in priority
setting; (3) guide practice in application of the nurs-
ing process; and (4) stimulate synthesis, analysis,
and application necessary for the development of
critical thinking skills and clinical judgment.
• Performance Checklists for Skills are included for
each chapter, beginning with Chapter 15.
• Application of the Nursing Process helps students
to make the connection between the conceptual
nursing process, often very dificult to comprehend,
and real-life patient care.
• The special section, Steps Toward Better Com-
munication, is written by an English-as-a-second-
language specialist to assist students with limited
proiciency in English to gain a greater command of
English pronunciation and medical language, while
reinforcing chapter content. This section is subdi-
vided into Vocabulary Building Glossary, Comple-
tion Exercise, Vocabulary Exercise, Word Attack
Skills, Communication Exercise, and Cultural
Points. There are examples and practice in appro-
priate dialogue needed for patient interaction and
delegation of tasks.
• Evolve Learning System Student Resources in-
clude the Anatomy and Physiology Body Spectrum
Coloring Book, a mathematics review, sugges-
tions for further reading, and other bonus content.
NCLEX-PN Examination–Style Interactive Review
Questions test your students’ knowledge and help
in preparation for licensure.
• Virtual Clinical Excursion (VCE) is an interac-
tive workbook CD-ROM that guides the student
through a multiloor virtual hospital in a hands-on
clinical experience. With limited clinical space for
LPN/LVN students, the VCE is an excellent oppor-
tunity for “hands-on” practice.
Teaching nursing is one of the most exciting and
gratifying experiences. I hope this textbook and its an-
cillaries make your job as an instructor easier and class
preparation more time-eficient. May your students
ind excitement and joy in learning and applying the
information you impart in the clinical setting.
Patricia Williams, MSN, RN, CCRN
To the Student
READING AND REVIEW TOOLS
• Objectives introduce the chapter topics.
• Key Terms are listed with page number references,
and dificult medical, nursing, or scientiic terms
are accompanied by simple phonetic pronuncia-
tions. Key terms are considered essential to under-
standing chapter content and are deined within
the chapter. Key terms are in color the irst time
they appear in the narrative and are briely de-
ined in the text, with complete deinitions in the
Glossary.
• Each chapter ends with a Get Ready for the NCLEX
Examination! section that includes (1) Key Points
that reiterate the chapter objectives and serve as a
useful review of concepts; (2) a list of Additional
Resources, including the Study Guide, Evolve Re-
sources, and Online Resources; (3) an extensive set
of Review Questions for the NCLEX Examination;
and (4) Critical Thinking Questions.
• Reader References located in the back of the text
cite evidence-based information and provide re-
sources for enhancing knowledge.
CHAPTER FEATURES
Skills are presented in a logical format with deined
purpose, relevant illustrations, and clearly deined and
numbered nursing steps. Each Skill includes icons that
serve as a reminder to perform the basic steps appli-
cable to all nursing interventions:
• Check orders.
• Gather necessary equipment and supplies.
• Introduce yourself.
• Check patient’s identiication.
• Provide privacy.
• Explain the procedure or intervention.
• Perform hand hygiene.
• Don gloves (if applicable).
Steps are short, nonillustrated skills with Actions
and Rationales.
xii
Assignment Considerations address situations in
which the registered nurse (RN) delegates tasks to the
LPN/LVN or when the LPN/LVN assigns tasks to nurse
assistants per the individual state nurse practice act.
Think Critically boxes encourage students to syn-
thesize information and apply concepts beyond the
scope of the chapter.
Home Care Considerations boxes focus on post-dis-
charge adaptations of medical-surgical nursing care to
the home environment.
Life-Span Considerations boxes highlight points
of care for the older adult population and appear
throughout the chapters to emphasize the changes that
occur with age and the adjustments needed for deliv-
ery of nursing care to older adults.
Focused Assessment boxes are located in each body
system overview chapter and include history taking
and psychosocial assessment, physical assessment,
and guidance on how to collect data/information for
speciic disorders.
Clinical Cues provide guidance and advice related
to the application of nursing care.
Nursing Care Plans, developed around speciic
case studies, include nursing diagnoses with an em-
phasis on patient goals and outcomes and questions to
promote critical thinking.
Safety Alerts emphasize the importance of main-
taining safety in patient care to protect patients, family,
health care providers, and the public from accidents,
spread of disease, and medication-related issues.
Health Promotion boxes emphasize healthy life-
style choices, preventive behaviors, and screening tests.
Cultural Considerations boxes explore select spe-
ciic cultural preferences and how to address the needs
of culturally diverse patients and families.
Patient Education boxes include step-by-step in-
structions and self-care guidelines.
 TO THE STUDENT xiii

Legal and Ethical Considerations boxes present per- Video clips portraying patient assessment available
tinent information about the legal issues and ethical on Evolve are referenced with icons in the margins
dilemmas that may face the practicing nurse. where applicable.

Complementary and Alternative Therapies boxes Evidence-Based Practice icons highlight current ref-
contain information on how nontraditional treatments erences to research in nursing and medical practice.
for medical-surgical conditions may be used to com-
plement traditional treatment.

Materials available on Evolve are referenced with

icons in the margins where related text appears.
Acknowledgments
DeWit’s Fundamental Concepts and Skills for Nursing is
the result of the creative efforts of many people. First
of all, I owe a deep debt of gratitude to Susan de Wit
for being a wonderful mentor and passing along such
a ine textbook and entrusting me with its future. You
set the bar very high and have taught me so very much
over the past several years.
I am especially grateful to the contributors, consul-
tants, and reviewers for their expertise, suggestions,
and inished work. Their perspectives from the various
geographic areas of the United States and Canada have
lent a broader viewpoint of current nursing practice.
The dedicated staff at Elsevier has provided tireless
support and expertise from the initial concept of the
book to the cohesive inished product. I am very grate-
ful to Nancy O’Brien, Senior Content Strategist, who
helped guide this project from start to inish and was
never too busy to answer any question no matter how
small. Bill Drone, Production Manager, made certain
that problems were solved and skillfully attended to
all aspects of production and printing of the text. Becky
Leenhouts, Senior Content Development Specialist,
was simply amazing with her creativity, diligence, and
attention to detail. Brittany Clements, Marketing Man-
ager, applied her creative ideas to promote the book
xiv
and announce its presence to students and instructors.
The design of the book, following the Threads design
of other Elsevier LPN/LVN texts, was provided by Re-
nee Duenow. Thanks for all the efforts of these diligent,
creative, professional people.
The artistry, many hours, and creative eye of Jack
Sanders, our photographer, lent the visual appeal and
clinical detail needed to illustrate the concepts and
skills of much of this edition, as well as the previous
editions. Ginger Navarro, RN, did a wonderful job
coordinating the photography shoots, facilities, and
models at PeaceHealth for the past three editions of
the book.
Many thanks also to PeaceHealth Southwest Wash-
ington Medical Center, the De Anza College Nursing
Skills and Simulation Lab, and Bay Area Surgical Spe-
cialists Surgery Center for the opportunity to photo-
graph within the facilities. Thanks to the many employ-
ees and nursing students who contributed their time and
talents to the ifth edition as models. Much appreciation
to all my nursing colleagues who comprise my e-mail
network across the country and who contributed exper-
tise and encouragement throughout the project.
Patricia Williams, MSN, RN, CCRN
Contents

UNIT I INTRODUCTION TO NURSING AND Licensure, 32

THE HEALTH CARE SYSTEM, 1 Professional Accountability, 33
Professional Discipline, 33
1 Nursing and the Health Care System, 1 Continuing Education, 33
Historical Overview, 1 Laws and Guidelines Affecting Nursing
Nursing in England and Europe, 1 Practice, 33
Nursing in North America, 2 Occupational Safety and Health
The Art and Science of Nursing, 3 Administration, 33
Evidence-Based Practice, 4 Child Abuse Prevention and Treatment Act, 34
Current Nursing Practice, 6 Discrimination, 34
Nursing Education Pathways, 7 Sexual Harassment, 34
Practical Nursing, 7 Good Samaritan Laws, 35
Registered Nursing, 7 Patient’s Rights, 35
Advanced Practice Nursing, 8 National Patient Safety Goals, 35
Delivery of Nursing Care, 8 Legal Documents, 36
Practice Settings, 9 The Medical Record, 36
Today’s Health Care System, 9 Health Insurance Portability and Accountability
Health Maintenance Organizations, 10 Act, 37
Preferred Provider Organizations, 10 Consents and Releases, 38
The Patient Protection and Affordable Witnessing Wills or Other Legal Documents, 39
Care Act, 11 Advance Directives, 39
Violations of Law, 39
2 Concepts of Health, Illness, Stress, and Health Negligence and Malpractice, 39
Promotion, 14 Common Legal Issues, 40
Health and Illness, 14 Decreasing Legal Risk, 42
Traditional Views of Health and Illness, 15 Ethics in Nursing, 43
Stages of Illness, 15 Codes of Ethics, 43
Current Views of Health and Illness, 16 Ethics Committees, 45
Implications of Current Views, 17 Ethical Dilemmas, 45
The Consumer Concept of Health and Illness, 17
Health and Illness Behaviors, 17
Cultural Inluences on Concepts of Health and UNIT II THE NURSING PROCESS, 48
Illness, 17
The Holistic Approach, 19 4 The Nursing Process and Critical
Maslow’s Theory of Basic Needs, 19 Thinking, 48
Homeostasis, 22 The Nursing Process, 48
Adaptation, 22 Critical Thinking, 50
The Effects of Stress, 26 Problem Solving and Decision Making, 50
Defense Mechanisms, 26 Skills for Critical Thinking, 51
Stress-Reduction Techniques, 26 Critical Thinking in Nursing, 51
Health Promotion and Illness Prevention, 26 Priority Setting and Work Organization, 53
Application of Problem Solving and Clinical
3 Legal and Ethical Aspects of Nursing, 30 Reasoning, 53
Source of Law, 31
Civil and Criminal Law, 32 5 Assessment, Nursing Diagnosis, and Planning, 57
Laws Related to Nursing Practice and Licensure, 32 Assessment (Data Collection), 57
Nurse Practice Act, 32 The Interview, 59
Scope of Practice, 32 Medical Records (Chart) Review, 59
xv
xvi CONTENTS
Physical Assessment, 62
Assessment in Long-Term Care, 63
Assessment in Home Health Care, 63
Analysis, 63
Nursing Diagnosis, 64
Etiologic Factors, 65
Deining Characteristics, 65
Prioritization of Problems, 65
Nursing Diagnosis in Long-Term Care, 66
Nursing Diagnosis in Home Health Care, 66
Planning, 66
Expected Outcomes (Goals), 66
Planning in Long-Term Facilities, 68
Planning in Home Health Care, 68
Interventions (Nursing Orders), 68
Documentation of the Plan, 69
6 Implementation and Evaluation, 73
Implementation, 73
Priority Setting, 73
Considerations for Care Delivery, 74
Interdisciplinary Care, 74
Implementing Care, 75
Documentation of the Nursing Process, 75
Evaluation, 76
Evaluation in Long-Term Care, 77
Evaluation in Home Health Care, 77
Revision of the Nursing Care Plan, 77
Quality Improvement, 77
Constructing a Nursing Care Plan, 78
UNIT III COMMUNICATION IN NURSING, 84
7 Documentation of Nursing Care, 84
Purposes of Documentation, 84
Documentation and the Nursing Process, 86
The Medical Record, 86
Methods of Documentation (Charting), 86
Source-Oriented or Narrative Charting, 88
Problem-Oriented Medical Record Charting, 88
Focus Charting, 89
Charting by Exception, 90
Computer-Assisted Charting, 90
Case Management System Charting, 94
The Documentation Process, 95
Accuracy in Documentation, 95
Brevity in Documentation, 95
Legibility and Completeness in
Documentation, 95
What to Document, 98
8 Communication and the Nurse-Patient
Relationship, 101
The Communication Process, 101
Factors Affecting Communication, 102
Communication Skills, 103
Therapeutic Communication Techniques, 104
Using Silence, 105
Asking Open-Ended Questions, 105
Restating, 106
Clarifying, 106
Using Touch, 106
Using General Leads, 106
Offering of Self, 106
Encouraging Elaboration, 106
Providing Patient Education, 106
Looking at Alternatives, 107
Summarizing, 107
Blocks to Effective Communication, 107
Changing the Subject, 107
Offering False Reassurance, 110
Giving Advice, 110
Using Defensive Comments, 110
Asking Prying or Probing Questions, 110
Using Clichés, 110
Listening Inattentively, 110
Interviewing Skills, 110
The Nurse-Patient Relationship, 111
Empathy, 111
Becoming Nonjudgmental, 112
Maintaining Hope, 112
Nurse-Patient Communication, 112
Communicating with the Hearing-Impaired
Patient, 113
Communicating with an Aphasic Patient, 113
Communicating with Older Adults, 113
Communicating with Children, 114
Communication Within the Health Care Team, 114
End-of-Shift Report, 114
Telephoning Primary Care Providers, 115
Assignment Considerations and Delegating, 115
Computer Communication, 117
Communication in the Home and
Community, 117
9 Patient Education and Health
Promotion, 120
Purposes of Patient Education, 120
Modes of Learning, 121
Assessment of Learning Needs, 121
Factors Affecting Learning, 122
The Patient Education Plan, 124
Resources for Patient Education, 125
Implementing the Plan, 125
Evaluation, 126
Documentation, 127
Coordination with Discharge Planning, 127
10 Delegation, Leadership, and
Management, 129
The Chain of Command, 130
Leadership Styles, 130
Keys to Effective Leadership, 130

Effective Communication and Relationships, 130
Clinical Competence and Conidence, 132
Organization, 132
Delegation, 132
Leadership Roles, 133
Beginning Leadership Roles, 133
Advanced Leadership Roles, 134
Management Skills for the Licensed Practical
Nurse/Licensed Vocational Nurse, 134
Time Management, 135
Using the Computer, 135
Receiving New Orders, 137
Taking Verbal Orders, 137
Documenting for Reimbursement, 138
Risk Management, 138
UNIT IV DEVELOPMENTAL,
PSYCHOSOCIAL, AND CULTURAL
CONSIDERATIONS, 141
11 Growth and Development: Infancy Through
Adolescence, 141
OVERVIEW OF STRUCTURE AND
FUNCTION, 142
Prenatal Development, 142
What Happens in the Germinal Stage of Prenatal
Development? 142
What Happens in the Embryonic Stage of Prenatal
Development? 142
What Happens in the Fetal Stage of Prenatal
Development? 142
What Causes Multiple Births? 142
Adolescent Development, 143
How Does a Girl Mature into a Woman? 143
How Does a Boy Mature into a Man? 143
Age Groups, 143
Theories of Development, 143
Principles of Growth and Development, 145
Prenatal Development, 145
Events in Prenatal Development, 145
Maternal Inluences, 146
Infants, 146
Nutrition, 146
Appearance and Capabilities of Newborns, 147
Physical Development, 147
Motor Development, 147
Cognitive Development, 148
Psychosocial Development, 148
Young Children, 149
Physical Development, 149
Motor Development, 150
Cognitive Development, 150
Psychosocial Development, 151
Day Care and Early Education, 152
Middle and Older Children, 152
Physical Development, 152
Cognitive Development, 152
CONTENTS xvii
Psychosocial Development, 153
Parenting, 153
Child Abuse, 154
Adolescents, 154
Physical Development, 154
Sexuality, 155
Cognitive Development, 155
Psychosocial Development, 155
Tasks of Adolescence, 156
Concerns in Adolescent Development, 156
12 Adulthood and the Family, 160
Adulthood as Continuing Change, 160
Theories of Development, 161
Schaie’s Theory of Cognitive Development, 161
Erikson’s Stages of Adult Psychosocial
Development, 161
Families, 161
Types of Families, 161
Historical Changes in Families, 162
Divorce and Families, 162
Young Adults, 162
Physical Development, 163
Health Concerns of Young Adults, 163
Cognitive Development, 164
Psychosocial Development, 164
Developmental Tasks, 165
Middle Adulthood, 166
Physical Development, 166
Health Concerns, 167
Cognitive Development, 167
Psychosocial Development, 168
13 Promoting Healthy Adaptation
to Aging, 172
Overview of Aging, 172
Theories of Aging, 173
Longevity, 173
Demographics, 174
Physical Changes, 174
Health Concerns, 176
Health Promotion Behaviors, 176
Cognitive Aspects of Aging, 177
Wisdom and Learning, 177
Memory Issues, 177
Employment and Retirement, 178
Health Promotion Behaviors, 178
Psychosocial Aspects of Aging, 178
Life Review, 178
Family Relationships, 178
Social Activity, 179
Living Arrangements, 179
Health Promotion Behaviors, 179
When a Parent Needs Help, 180
Planning Ahead, 180
Observing Changes, 180
Resources for Families, 180
xviii CONTENTS

14 Cultural and Spiritual Aspects of Patient Care, 183 UNIT V BASIC NURSING SKILLS, 216
Transcultural Care, 184
What Is Culture? 184 16 Infection Prevention and Control: Protective
Understanding Spirituality, 185 Mechanisms and Asepsis, 216
Major Religions in the United States and Infectious Agents, 217
Canada, 185 Bacteria, 217
Christianity, 185 Prions, 219
Islam, 186 Viruses, 219
Judaism, 188 Protozoa, 219
Hinduism, Buddhism, and Taoism, 188 Viruses, 219
Developing Cultural Competence, 189 Rickettsia, 219
Barriers to Cultural Competence, 190 Fungi, 219
Cultural Differences, 190 Helminths, 219
Communication, 191 Other Infectious Agents, 219
View of Time, 191 Process (Chain) of Infection, 219
Family Organization and Structure, 191 Causative Agent (Link One), 219
Nutritional Practices, 191 Reservoir, 220
Death and Dying, 192 Mode of Transfer, 220
Health Care Beliefs, 192 Portal of Entry, 220
Susceptibility to Disease, 194 Susceptible Host, 221
Nursing Process in Transcultural Nursing, 194 Body Defenses Against Infection, 223
Assessment (Data Collection), 194 Inlammatory Response, 224
Nursing Diagnosis, 195 Immune Response, 224
Planning, 195 Asepsis and Control of Microorganisms, 226
Implementation, 195 Medical Asepsis and Surgical Asepsis, 226
Evaluation, 196 Hand Hygiene, 227
Standard Precautions, 231
15 Loss, Grief, and End-of-Life Care, 198 Cleaning and Disinfection, 236
Nurses’ Attitudes Toward End-of-Life Sepsis in the Home Environment, 237
Care, 199 Infection Control Surveillance, 237
Change, Loss, and Grief, 199
Change, 199 17 Infection Prevention and Control in the Hospital
Loss, 199 and Home, 242
Grief, 200 Infection, 242
Stages of Grief, 200 Stages of Infection, 242
Death and Dying, 201 Health Care–Associated Infections, 243
End-of-Life Care Within the Health Care System, Infection Prevention and Control, 243
201 Personal Protective Equipment, 245
Hospice and Palliative Care, 201 Needle Stick Injuries, 246
The Dying Process, 203 Application of the Nursing Process, 246
Nursing and the Dying Process, 204 Assessment (Data Collection), 246
Application of the Nursing Process, 205 Nursing Diagnosis, 246
Assessment (Data Collection), 205 Planning, 247
Nursing Diagnosis, 205 Implementation, 247
Planning, 205 Evaluation, 260
Implementation, 206
Evaluation, 208
Signs of Impending Death, 208 18 Safely Lifting, Moving, and Positioning
Physical Signs, 208 Patients, 267
Psychosocial and Spiritual Aspects of OVERVIEW OF THE STRUCTURE AND
Dying, 208 FUNCTION OF THE MUSCULOSKELETAL
Legal and Ethical Aspects of Life-and-Death SYSTEM, 268
Issues, 209 Which Structures Are Involved in Positioning and
Advance Directives, 209 Moving Patients? 268
Euthanasia, 209 What Are the Functions of Bones for Positioning
Adequate Pain Control, 210 and Moving Patients? 268
Organ and Tissue Donation, 210 What Are the Functions of Muscles for
Postmortem (After Death) Care, 210 Positioning and Moving Patients? 268
 CONTENTS xix

What Changes in the System Occur with Alternatives to Protective Devices, 335
Aging? 268 Principles Related to the Use of Protective
Principles of Body Movement for Nurses, 269 Devices, 336
Obtain Help Whenever Possible, 269 Documentation of the Use of Protective
Use Your Leg Muscles, 269 Devices, 339
Provide Stability for Movement, 270
Use Smooth, Coordinated Movements, 270 21 Measuring Vital Signs, 343
Keep Loads Close to the Body, 270 Overview of Structure and Function Related to
Keep Loads near the Center of Gravity, 270 the Regulation of Vital Signs, 344
Pull and Pivot, 271 How Is Body Heat Produced? 344
Principles of Body Movement for Patients, 271 What Factors Affect Body Heat Production? 344
Hazards of Improper Alignment and How Is Body Temperature Regulated? 344
Positioning, 271 How Does Fever Occur, and What Are Its
Application of the Nursing Process, 271 Physiologic Effects? 345
Assessment (Data Collection), 271 What Physiologic Mechanisms Control
Nursing Diagnosis, 272 the Pulse? 345
Planning, 272 What Is Respiration? 345
Implementation, 272 What Are the Organs of Respiration? 346
Evaluation, 288 How Is Respiration Controlled? 347
What Is Blood Pressure? 347
19 Assisting with Hygiene, Personal Care, Skin Care, What Physiologic Factors Directly Affect the
and the Prevention of Pressure Injuries, 295 Blood Pressure? 347
Overview of the Structure and Function of the What Changes Occur in Vital Signs
Integumentary System, 296 with Aging? 347
What Is the Structure of the Skin? 296 Measuring Body Temperature, 347
What Are the Functions of the Skin and Its Factors Inluencing Temperature Readings, 348
Structures? 296 Problems of Temperature Regulation, 349
What Changes in the System Occur with Measuring Body Temperature, 350
Aging? 296 Glass Thermometers, 351
Application of the Nursing Process, 296 Electronic Thermometers, 352
Assessment (Data Collection), 296 Disposable Thermometers, 355
Nursing Diagnosis, 301 Application of the Nursing Process, 355
Planning, 301 Assessment (Data Collection), 355
Implementation, 301 Nursing Diagnosis, 355
Evaluation, 319 Planning, 355
Implementation, 356
Evaluation, 356
20 Patient Environment and Safety, 321 Measuring the Pulse, 357
Factors Affecting the Environment, 321 Common Pulse Points, 357
Temperature, 321 Pulse Rate, 358
Ventilation, 322 Pulse Characteristics, 360
Humidity, 322 Application of the Nursing Process, 361
Lighting, 322 Measuring Respirations, 361
Odor Control, 322 Respiratory Patterns, 362
Noise Control, 322 Measuring Oxygen Saturation of the
Interior Design, 323 Blood, 364
Neatness, 323 Measuring the Blood Pressure, 364
Privacy, 323 Equipment Used for Measuring Blood
Patient Unit, 323 Pressure, 365
Beds, 323 Korotkoff Sounds, 369
Bed Positions, 323 Hypertension, 369
Bed Making, 324 Hypotension, 370
Safety, 329 Application of the Nursing Process, 370
Hazards, 329 Pain, the Fifth Vital Sign, 371
Hazardous Materials, 332 Automated Vital Sign Monitors, 371
Protective Devices, 335 Documenting Vital Signs, 371
Legal Implications of Using Protective Devices, 335 Recording Temperature Measurements, 371
xx CONTENTS

Recording Pulse Measurements, 372 Distribution of Body Fluids, 438

Recording Respiration Measurements, 372 Movement of Fluid and Electrolytes, 438
Recording Blood Pressure Measurements, 372 Fluid and Electrolyte Imbalances, 440
Evaluating Vital Sign Trends, 372 Deicient Fluid Volume, 441
Excess Fluid Volume, 442
22 Assessing Health Status, 375 Electrolyte Imbalances, 442
Data Collection and Assessment, 375 Acid-Base Balance, 447
Application of the Nursing Process, 376 pH, 447
Assessment (Data Collection), 376 Bicarbonate, 447
Nursing Diagnosis, 388 Control Mechanisms, 447
Planning, 388 Acid-Base Imbalances, 447
Implementation, 388 Respiratory Acidosis, 449
Evaluation, 396 Metabolic Acidosis, 449
Respiratory Alkalosis, 449
23 Admitting, Transferring, and Discharging Metabolic Alkalosis, 450
Patients, 398 Application of the Nursing Process, 450
Types of Admissions, 398 Assessment (Data Collection), 450
Routine Admissions, 398 Nursing Diagnosis, 451
Emergency Admissions, 399 Planning, 451
Admission Process, 399 Implementation, 451
Preadmission Procedures and Evaluation, 455
Requirements, 399
Day of Admission, 399 26 Concepts of Basic Nutrition and Cultural
Reactions to Admission, 402 Considerations, 458
Plan of Care, 402 Overview of the Structure and Function of the
Patient Transfer to Another Hospital Gastrointestinal System, 459
Unit, 402 Which Structures Are Involved in the
Discharging the Patient, 403 Gastrointestinal (Digestive) System? 459
Discharge to an Extended-Care or Rehabilitation What Are the Functions of the Organs of the
Facility, 403 Gastrointestinal System? 459
Discharge Home, 403 What Changes in the Digestive System Occur
Death of a Patient, 404 with Aging? 460
Providing Support for Signiicant Others, 404 Dietary Guidelines, 460
Pronouncement of Death, 404 USDA Myplate and the 2015 Dietary Guidelines
Autopsies, 405 for Americans, 460
Organ Donation, 405 Protein, 462
Functions of Protein, 462
24 Diagnostic Tests and Specimen Collection, 407 Food Sources of Protein, 462
Diagnostic Tests and Procedures, 408 Dietary Reference Intakes of Protein, 462
Application of the Nursing Process, 408 Protein Deiciency, 463
Assessment (Data Collection), 408 Protein Excess, 463
Nursing Diagnosis, 408 Vegetarian Diets, 463
Planning, 408 Carbohydrates, 464
Implementation, 408 Functions of Carbohydrates, 464
Evaluation, 430 Simple Carbohydrates, 464
Complex Carbohydrates (Starches), 464
Recommendations for Intake, 464
UNIT VI MEETING BASIC PHYSIOLOGIC Fiber, 465
NEEDS, 436 Fats (Lipids), 465
Functions of Fat, 465
25 Fluid, Electrolyte, and Acid-Base Food Sources of Fat, 466
Balance, 436 Vitamins, 466
Composition of Body Fluids, 436 Minerals, 467
Water, 436 Water, 469
Electrolytes, 438 Factors that Inluence Nutrition, 469
Nonelectrolytes, 438 Age, 472
Blood, 438 Illness, 472
 CONTENTS xxi

Emotional Status, 472 What Are the Functions of the Respiratory

Economic Status, 472 Structures? 509
Religion, 472 What Changes Occur with Aging That Affect
Culture, 472 Respiration? 509
Food Safety, 472 Hypoxemia, 510
Cultural Inluences on Nutrition, 473 Symptoms of Hypoxia, 510
African American, 473 Pulse Oximetry, 511
Hispanic American, 473 Airway Obstruction and Respiratory Arrest, 511
Asian American, 473 Clearing Respiratory Secretions, 513
Middle Eastern American, 473 The Effective Cough, 513
Nutrition Counseling, 473 Postural Drainage, 518
Nutritional Needs Throughout the Life Span, 473 Oxygen Administration, 518
Infants, 473 Cannula, 522
Toddlers and Preschool Children, 475 Masks, 522
School-Age Children, 475 Artiicial Airways, 522
Adolescents, 475 Nasopharyngeal Suctioning, 524
Adults, 475 Tracheobronchial Suctioning, 526
Older Adults, 476 Tracheostomy, 529
Application of the Nursing Process, 477 Chest Drainage Tubes, 529
Assessment (Data Collection), 477 Application of the Nursing Process, 530
Nursing Diagnosis, 479 Assessment (Data Collection), 530
Planning, 479 Nursing Diagnosis, 532
Implementation, 479 Planning, 532
Evaluation, 480 Implementation, 533
Evaluation, 539
27 Nutritional Therapy and Assisted
Feeding, 484 29 Promoting Urinary Elimination, 541
The Goals of Nutritional Therapy, 485 Overview of Structure and Function of the
The Postoperative Patient, 487 Urinary System, 542
Health Issues Related to Nutrition, 487 Which Structures Are Involved in Urinary
Feeding and Eating Disorders, 487 Elimination? 542
Obesity, 489 What Are the Functions of the Urinary Structures
Pregnancy, 490 for Elimination? 542
Substance-Related and Addictive Disorders, 490 What Factors Can Interfere with Urinary
Disease Processes That Beneit from Nutritional Elimination? 543
Therapy, 491 What Changes in the System Occur with
Cardiovascular Disease, 491 Aging? 543
Diabetes Mellitus, 491 Normal Urinary Elimination, 543
HIV/AIDS, 493 Factors Affecting Normal Urination, 543
Assisted Feeding, 494 Characteristics of Normal Urine, 543
Nasogastric and Enteral Tubes, 495 Alterations in Urinary Elimination, 544
Percutaneous Endoscopic Gastrostomy or Application of the Nursing Process, 545
Jejunostomy Tubes, 496 Assessment (Data Collection), 545
Feeding Tubes and Pumps, 500 Nursing Diagnosis, 547
Total Parenteral Nutrition, 504 Planning, 548
Application of the Nursing Process, 505 Implementation, 548
Assessment (Data Collection), 505 Evaluation, 570
Nursing Diagnosis, 505
Planning, 505 30 Promoting Bowel Elimination, 572
Implementation, 505 Overview of the Structure and Function of the
Evaluation, 505 Intestinal System, 573
Which Structures of the Intestinal System Are
28 Assisting with Respiration and Oxygen Involved in Waste Elimination? 573
Delivery, 508 What Are the Functions of the Intestines? 573
Overview of the Structure and Function of the What Effect Does Aging Have on the Intestinal
Respiratory System, 508 Tract? 574
Which Structures Are Involved in Respiration? 508
xxii CONTENTS

Characteristics of Stool, 574 Bioield Therapies, 616

Normal Characteristics of Stool, 574
Abnormal Characteristics of Stool, 574
Hypoactive Bowel and Constipation, 574
Hyperactive Bowel and Diarrhea, 576
Fecal Incontinence, 577
Application of the Nursing Process, 577
Assessment (Data Collection), 577
Nursing Diagnosis, 577
Planning, 577
Implementation, 578
Evaluation, 580
Rectal Suppositories, 580
Enemas, 580
Types of Enemas, 580
Amount and Temperature of Solution, 580
Recommended Position, 581
Rectal Tube, 581
Fecal Impaction, 583
Bowel Training for Incontinence, 584
Bowel Ostomy, 585
Ostomy Care, 587
31 Pain, Comfort, and Sleep, 593
Pain and Discomfort, 594
Theories of Pain, 594
Types of Pain, 595
Application of the Nursing Process, 597
Assessment (Data Collection), 597
Nursing Diagnosis, 599
Planning, 599
Implementation, 599
Evaluation, 608
Sleep, 608
Functions of Sleep, 609
Stages of Sleep, 609
Normal Sleep Requirements, 609
Factors Affecting Sleep, 610
Sleep Disorders, 610
Application of the Nursing Process, 611
Assessment (Data Collection), 611
Nursing Diagnosis, 611
Planning, 611
Implementation, 611
Evaluation, 612
32 Complementary and Alternative
Therapies, 614
Complementary and Alternative Medicine, 614
Mind and Body Interventions, 615
Acupuncture, 615
Yoga, 615
Chiropractic, 616
Massage Therapy, 616
Relaxation Therapy, 616
Imagery, 616
Meditation, 616
Biofeedback, 616
Hypnotherapy, 617
Music, Art, and Dance Therapy, 617
Humor, 617
Prayer, 617
Natural Products, 617
Herbal Therapy and Dietary
Supplements, 617
Aromatherapy, 619
Other Complementary Interventions, 619
Homeopathic Medicine, 619
Naturopathic Medicine, 619
Traditional Chinese Medicine, 619
Ayurveda, 619
Shamanism, 619
Folk Medicine, 620
American Indian Medicine, 620
The Nurse’s Role in Complementary and
Alternative Therapies, 620
UNIT VII MEDICATION
ADMINISTRATION, 622
33 Pharmacology and Preparation for Drug
Administration, 622
Pharmacology, 622
Classiication of Drugs, 623
Legal Control of Drugs, 625
Basic Concepts of Pharmacology, 626
Medication Administration and Safety, 629
Considerations for Infants and Children, 631
Considerations for the Older Adult, 632
Considerations for Home Care, 633
Problems of Nonadherence, 633
Application of the Nursing Process, 634
Assessment (Data Collection), 634
Nursing Diagnosis, 636
Planning, 636
Implementation, 637
Evaluation, 641
34 Administering Oral, Topical, and Inhalant
Medications, 644
Nursing Responsibilities in Medication
Administration, 645
Medication Orders, 645
Types of Orders, 646
Regularly Scheduled or Routine Medication
Orders, 647
Dosage of Medications, 647
Routes of Oral and Topical Medication
Administration, 647
Medication Administration and
Technology, 648
Medication Administration Record, 649
 CONTENTS xxiii

Medication Administration Systems, 649 Application of the Nursing Process, 710

Unit-Dose System, 649 Assessment (Data Collection), 710
Prescription System, 650 Nursing Diagnosis, 711
Preparation of Oral Controlled Substances from a Planning, 711
Dispenser, 650 Implementation, 712
Topical Drugs, 652 Evaluation, 731
Application of the Nursing Process, 652
Assessment (Data Collection), 652
Nursing Diagnosis, 652 UNIT VIII CARE OF THE SURGICAL
Planning, 653 AND IMMOBILE PATIENT, 733
Implementation, 653
Evaluation, 669 37 Care of the Surgical Patient, 733
Medication Errors, 669
Reasons for Surgery, 734
Patients at Higher Risk for Surgical
35 Administering Intradermal, Subcutaneous, and
Complications, 734
Intramuscular Injections, 673
Perioperative Nursing, 735
Principles of Parenteral Injections, 674 Enhancements to Surgical Technique, 735
Routes for Parenteral Medication, 674 Laser Surgery, 735
Intradermal Route, 675 Fiberoptic Surgery, 735
Subcutaneous Route, 675 Robotic Surgery, 736
Intramuscular Route, 675 Anesthesia, 736
Injection Equipment, 676 General Anesthesia, 736
Types of Syringes, 676 Regional Anesthesia, 736
Measurement Scales, 676 Procedural (Moderate) Sedation Anesthesia, 736
Needle Gauge and Length, 676 Local Anesthesia, 736
Preventing Needle Sticks, 677 Preoperative Procedures, 737
Syringe and Needle Selection, 678 Surgical Consent, 737
Preparing the Syringe for Use, 678 Surgical Site Identiication, 737
Parenteral Solutions, 678 Physical Examination, 737
Using a Medication Ampule, 678 Application of the Nursing Process, 738
Using a Medication Vial, 680 Preoperative Care, 738
Reconstitution of a Drug, 681 Assessment (Data Collection), 738
Compatibility of Medications, 681 Nursing Diagnosis, 739
Application of the Nursing Process, 683 Planning, 739
Assessment (Data Collection), 683 Implementation, 739
Nursing Diagnosis, 683 Evaluation, 743
Planning, 684 Intraoperative Care, 747
Implementation, 684 Role of the Scrub Person and Circulating Nurse, 748
Evaluation, 696 Postanesthesia Immediate Care, 748
Postanesthesia Care in the Same-Day Surgery
36 Administering Intravenous Solutions and Unit, 748
Medications, 699 Postoperative Care, 749
Intravenous Therapy, 700 Assessment (Data Collection), 749
Licensed Practical Nurse/Licensed Nursing Diagnosis, 749
Vocational Nurse’s Role in Intravenous Planning, 750
Therapy, 700 Implementation, 751
Types of Intravenous Solution, 700 Evaluation, 755
Equipment for Intravenous
Administration, 703 38 Providing Wound Care and Treating Pressure
Administration Sets, 703 Injuries, 759
Infusion Pumps and Controllers, 705 Types of Wounds and the Healing Process, 760
Venous Access Devices, 707 Phases of Wound Healing, 761
Complications of Intravenous Therapy, 709 Factors Affecting Wound Healing, 762
Iniltration, 709 Age, 762
Extravasation, 709 Nutrition, 762
Phlebitis, 710 Lifestyle, 762
Bloodstream Infection, 710 Medications, 765
Other Complications, 710 Infection, 765
xxiv CONTENTS

Chronic Illness, 765 Alteration in Elimination, 819

Complications of Wound Healing, 765 Urinary Incontinence, 819
Hemorrhage, 765 Constipation and Fecal Impaction, 820
Infection, 765 Alteration in Nutrition, 820
Dehiscence and Evisceration, 766 Nursing Interventions for Nutritional Support, 821
Treatment of Wounds, 766 Sensory Deicits, 821
Wound Closure, 766 Vision Deicits, 821
Drains and Drainage Devices, 767 Hearing Deicit, 823
Débridement, 768 Sexuality, 823
Dressings, 769 Polypharmacy, 824
Binders, 770 Nursing Interventions for Polypharmacy, 825
Negative Pressure Wound Therapy, 771
Treatment of Pressure Injuries or Vascular 41 Common Psychosocial Care Problems of the Older
Ulcers, 772 Adult, 830
Application of the Nursing Process, 772 Changes in Cognitive Functioning in Older
Assessment (Data Collection), 772 Adults, 830
Nursing Diagnosis, 773 Assessment of Cognitive Changes in Older
Planning, 773 Adults, 831
Implementation, 773 Common Cognitive Disorders in Older
Evaluation, 787 Adults, 831
Confusion, 831
39 Promoting Musculoskeletal Function, 789 Delirium, 831
Systemic Effect of Immobilization, 790 Dementia, 832
Psychosocial Effects of Immobilization, 791 Alzheimer Disease, 834
Types of Immobilization, 792 Safety for the Cognitively Impaired, 835
Splints, 792 Behaviors Associated with Cognitive
Traction, 792 Disorders, 835
Casts, 794 Depression, Alcoholism, and Suicide, 837
External Fixators, 795 Interventions for Depression, Alcoholism, and
Devices Used to Prevent Problems of Suicide Prevention, 838
Immobility, 796 Crimes Against Older Adults, 839
Specialty Beds, 796 Elder Abuse, 839
Pressure Relief Devices, 796 Scams and White-Collar Crime, 840
Continuous Passive Motion Machine, 797 Future Issues of Concern to Older Adults, 840
Therapeutic Exercise, 797 Planning for the Future, 841
Application of the Nursing Process, 798
Assessment (Data Collection), 798
Nursing Diagnosis, 799 APPENDIXES
Planning, 799 A Standard Steps for All Nursing Procedures, 843
Implementation, 800 B NFLPN Nursing Practice Standards for the
Evaluation, 812 Licensed Practical/Vocational Nurse, 845
C American Nurses Association Code of Ethics for
Nurses, 847
D Standard Precautions, 848
UNIT IX CARING FOR THE ELDERLY, 815
E Most Common Laboratory Test Values, 851
40 Common Physical Care Problems of the Older F NANDA-I Approved Nursing Diagnoses,
Adult, 815 2015-2017, 854
Getting Older, 815 Reader References, 857
Immobility, 815
Nursing Interventions to Promote Mobility, 816 Glossary, 866
Preventing Falls, 818 Index, 882
Unit I Introduction to Nursing and the Health Care System

ch a p te r

Nursing and the Health Care System 1

http://evolve.elsevier.com/Williams/fundamental

Objectives
Upon completing this chapter, you should be able to do the following:
Theory
1. Describe Florence Nightingale’s inluence on nurses’
training.
2. Explain why nursing is both an art and a science.
3. Deine evidence-based practice and explain why it is
important in nursing.
4. Trace the growth of nursing in the United States from the
Civil War to the present.
5. Discuss the ways in which the desirable attributes of the
nurse might be demonstrated.
6. Identify the educational ladder that is available to nurses.
7. Describe educational pathways open to the LPN/LVN
upon graduation.
8. Compare methods of delivery of nursing care.
9. List four practice settings in which LPNs/LVNs may ind
employment.
10. Discuss today’s health care system, its components, and
changes proposed.
11. Explain how an HMO and a PPO differ.
12. Relate how the recent health care legislation has affected
your own health care.
Clinical Practice
1. Write your own deinition of nursing.
2. Discuss how the standards of practice for the LPN/LVN
are applied in the clinical setting.
3. List the practice areas in the community in which you
could be employed as a vocational nurse.

Key Terms
apprenticeship (ă-PRĔN-tĭ-shĭp, p. 2) interventions (p. 3)
aseptically (ā-SĔP-tĭk-ăl-lē, p. 4) invasive procedures (ĭn-VĀ-sĭv, p. 3)
capitated cost (p. 11) nursing process (p. 6)
clinical practice guidelines (p. 5) nursing theory (p. 4)
diagnosis-related groups (DRGs) (dī-ăg-NŌS-ĭs, p. 9) practice acts (p. 6)
evidence-based nursing (p. 4) preferred provider organizations (PPOs) (p. 10)
health maintenance organizations (HMOs) (p. 10) transition to practice (p. 6)
implement (ĬM-plĕ-mĕnt, p. 6)

As family groups banded together into communities,

Concepts Covered in This Chapter certain individuals extended themselves to care for
• Care coordination the ill, the helpless, and older adults. During this pe-
• Collaboration riod, nursing consisted of comforting, caring for basic
• Communication needs, and using herbal remedies.
• Evidence
• Health care organizations NURSING IN ENGLAND AND EUROPE
• Health policy
• Health care law As civilizations appeared, nurses were under the direc-
• Patient education tion of the priest-physicians because illness was often
• Professionalism believed to be caused by sin or the gods’ displeasure.
With the growth of Christianity, caring for the sick be-
came a function of religious orders. The Christian St.
Paul introduced a deaconess named Phoebe, a prac-
HISTORICAL OVERVIEW
tical nurse, to Rome. She was the irst visiting nurse.
The art of nursing arose in primitive times, when Both men and women tended the sick during this pe-
one person simply cared for another who was sick. riod. Nursing became a recognized vocation during
1
2 UNIT I Introduction to Nursing and the Health Care System
the Crusades (AD 1100–1200) as hospitals were built
to care for the large number of pilgrims needing health
care.
The service provided by the religious orders in Eng-
land changed with the break between King Henry
VIII of England and the Catholic Church in the 1500s.
The nuns and priests were sent out of the country. The
patients in their hospitals were abandoned; the hos-
pitals became the responsibility of the government.
Criminals, widows, and orphans were recruited,
and in exchange for housing and food, they tended
the sick. The drunken nurse-midwives Sairey Gamp
and Betsy Prig, as portrayed in Charles Dickens’ 1849
novel Martin Chuzzlewit, were typical of hospital
nurses at the time. Health care conditions became very
bad.
Florence Nightingale
In the mid-1800s Florence Nightingale, an English-
woman, felt a calling by God to become a nurse.
Nightingale studied in Germany with a Protestant or-
der of women who cared for the sick. She went on to
reform and manage a charity hospital for ill govern-
esses. During the Crimean War, Florence Nightingale
asked the Secretary of War to allow her to train wom-
en to care for the sick and wounded. By cleaning up
the wards and improving ventilation, sanitation, and
nutrition, her group of 38 nurses lowered the death
rate from 60% to 1%. The Nightingale nurses made
their rounds after dark with the aid of a lighted oil
lamp. The lamp became the oficial symbol of nurs-
ing. Florence Nightingale kept records and statistics
that reinforced her theories of care, many of which are
still valid today.
Funds were given out of gratitude by the service
members and their families. These funds were used to
begin the irst Nightingale training school for nurses,
located in England at St. Thomas Hospital, which oper-
ates to this day. Nightingale based her curriculum on
the following beliefs:
• Nutrition is an important part of nursing care.
• Fresh, clean air is beneicial to the sick.
• Sick people need occupational and recreational
therapy.
• Nurses should help identify and meet patients’
personal needs, including providing emotional
support.
• Nursing should be directed toward two conditions:
health and illness.
• Nursing is distinct and separate from the practice of
medicine and should be taught by nurses.
• Continuing education is needed for nurses.
These beliefs are still the foundation of nursing
today.
Think Critically
How is the tradition of combining religion and medical care still
evident today?
NURSING IN NORTH AMERICA
Nursing care was sadly lacking during the Civil War
in America. The Union government inally appointed
Dorothea Dix, a social worker, to organize women vol-
unteers to provide nursing care for the soldiers. These
workers were similar to the nursing assistants of today.
Clara Barton took volunteers into the ield hospitals to
care for soldiers of both armies. She later founded the
American Red Cross. Lillian Wald took nursing out
into the community, and in 1893, she and Mary Brew-
ster established the Henry Street Settlement Service
in New York City, which focused on the health needs
of poor people who lived in tenements. In the period
following the Civil War, nurses’ training was essential-
ly an apprenticeship (learning by doing). Over time, the
schooling became more formal and the hospital-based
training period lengthened from 6 months to 3 years.
Graduates of the training program received a diploma.
In an era when women were expected to remain at
home and be subservient to men, nurses’ training be-
came a way to obtain further education and employ-
ment that could provide independence for women.
The training in the Nightingale schools varied con-
siderably from that of the US nursing schools. The
Nightingale program was well organized, with classes
held separately from practical experience on the wards.
The core curriculum was the same in all schools. In-
struction was provided by a trained nurse and was fo-
cused on nursing care.
In the United States, the students staffed the hospital
and worked without pay. There were no formal classes;
education was achieved through work. There was no set
curriculum, and content varied depending on the type
of cases present in the hospital. Instruction was done
at the bedside by the physician and, therefore, came
from a medical viewpoint. In 1892, the New York Young
Women’s Christian Association (YWCA) started the irst
oficial school for practical nursing, the Ballard School,
which offered a 3-month course. Students were trained
to care for infants, children, and older adults in the home.
The National League of Nursing Education issued for-
mal standards for practical nursing education. In 1918, a
group of women opened the Household Nursing School
in Boston to train nurses to care for the sick at home.
Later this school was called the Shepard-Gill School of
Practical Nursing. During World War I, the Army School
of Nursing was opened to train more practical nurses.
In the 20th century, nurses moved out into the com-
munity. They worked with the poor in the cities; pro-
vided midwifery services; and taught prenatal, obstet-
ric, and child care (Fig. 1.1). The irst African American
nurses to serve in the US Army during World War I
paved the way for others to follow (Fig. 1.2). World
War II created a great demand for nurses in military
hospitals, and training programs had to be increased
(Fig. 1.3). Nurses served on many fronts and on hospi-
tal ships (Fig. 1.4). Congress passed a bill to draft nurs-
es, but the declaration of peace occurred before it was

FIGURE 1.1 A Red Cross public health nurse poses with her Model
T Ford before setting out on her rounds. (Photo courtesy American
National Red Cross.)
FIGURE 1.2 Some of the irst African American nurses to serve with
the US Army standing outside their quarters at Camp Sherman in
Chillicothe, Ohio. (Photo courtesy American National Red Cross.)
enacted. Nurses continue to serve in times of military
crisis, as in Iraq and Afghanistan, and American mili-
tary nurses currently provide essential care to service
members and local civilians whenever and wherever
our armed services are deployed (Fig. 1.5).
THE ART AND SCIENCE OF NURSING
There are many deinitions of nursing, and as you prog-
ress through your nursing career, ideas about what
nursing is will grow and change. Among the various
deinitions, the following four common goals appear:
• To promote wellness
• To prevent illness
• To facilitate coping
• To restore health
Nursing and the Health Care System CHAPTER 1 3
FIGURE 1.3 A group of nursing students during the 1930s or 1940s in
an anatomy class at Walter Reed General Hospital, Washington, DC.
(Photo courtesy of The US National Library of Medicine.)
FIGURE 1.4 Nurses caring for patients on a hospital ship. (Photo
courtesy of The US National Library of Medicine.)
To accomplish these goals, the practical nurse takes
on the role of caregiver, educator, collaborator, advo-
cate, and manager.
QSEN Considerations: Teamwork and Collaboration
Roles of the Practical Nurse
Collaboration with the health care team is an important role of
the practical nurse.
Caregiving skills are interventions aimed at restor-
ing and maintaining a person’s health. Interventions
are actions taken to improve, maintain, or restore
health or prevent illness. An example would be assist-
ing a patient with hygiene tasks such as bathing and
brushing the teeth. Today, caregiving skills extend to
using highly technical equipment for medical thera-
pies and protecting the safety of the patient undergo-
ing invasive procedures (procedures that require entry
4 UNIT I Introduction to Nursing and the Health Care System
FIGURE 1.5 A nurse dispensing medication to a civilian patient in Iraq.
(Courtesy of Sargent First Class Christina Bhatti.)
into the body). Nurses provide both physical and emo-
tional care to patients. By performing various tasks
and working closely with the patient, nurses develop a
concern for the patient’s well-being.
QSEN Considerations: Patient-Centered Care
Growth Toward Wellness
The nurse’s goal is to encourage growth toward wellness so
that the patient can once again be self-reliant.
Patient education and health counseling are func-
tions of the practical nurse and are directed toward
promoting wellness and preventing illness. Teaching
about medications and how to aseptically (without in-
troducing infectious material) change dressings are ex-
amples of this role. Emotional support and comfort are
incorporated in care, and the nurse is an advocate for
the patient during times of health-related stress.
The licensed practical nurse (LPN), called a licensed
vocational nurse (LVN) in California and Texas, collab-
orates with the registered nurse (RN) and other mem-
bers of the health care team to provide continuity of
care and care coordination.
QSEN Considerations: Teamwork and Collaboration
Care Planning for the Patient
Care for the patient is planned jointly by all health care team
members.
Minor tasks such as taking vital signs or giving a
bed bath may be assigned to the nursing assistant or
other ancillary personnel.
Therapeutic communication techniques facilitate a
patient’s ability to cope. Active listening is a therapeu-
tic technique that helps the patient to consider possible
solutions when a problem occurs. Establishing a good
nurse-patient relationship is necessary to gain the pa-
tient’s trust so that patient education and other com-
munications are well received.
Initially nursing was an art: it consisted of perform-
ing certain acts of care skillfully, with intuition and cre-
ativity. Over time, a scientiic base was combined with
the art of nursing. From this body of knowledge, the
nurse can choose interventions that are most likely to
produce desired outcomes for the patient.
As this scientiic base for nursing has developed,
various scholars have proposed theories concerning
the process of nursing. A nursing theory is a statement
about relationships among concepts or facts, based on
existing information. Nursing theorists generally base
their beliefs on the relationships among humans, the
environment, health, and nursing. Table 1.1 provides
a brief explanation of some of the major nursing theo-
ries. A particular theory may be the basis of a nursing
school’s curriculum structure and part of its philoso-
phy of how nursing care is delivered. Nursing strives
to maintain recognition as a profession. For this rea-
son, ongoing research is essential to add to the scien-
tiic knowledge base.
EVIDENCE-BASED PRACTICE
The promotion of evidence-based nursing has become
stronger around the world over the last 2 decades. Ev-
idence-based nursing describes nursing care that uses
the best research evidence coupled with the clinical ex-
pertise of the clinician, considering the values of the
patient (Stevens, 2013).
QSEN Considerations: Quality Improvement
Interpreting Research
Learning the skills to discriminate between high-quality and
lawed research and to interpret study results is important in
becoming a practical nurse.
Nurses are being strongly encouraged to seek evi-
dence for their practice throughout their careers. Evi-
dence-based practice involves using the best scientiic
evidence from research to guide nursing care and im-
prove patient outcomes (Academy of Medical-Surgical
Nurses, 2014).
QSEN Considerations: Evidence-Based Practice
About Evidence-Based Practice
Hypoglycemia is always a potential adverse effect of insu-
lin therapy. Evidence-based practice consists of using your
expertise, patient preferences and values, and a problem-
solving approach to clinical practice to make decisions about
 Nursing and the Health Care System CHAPTER 1 5

Table 1.1 Selected Nursing Theories

THEORIST
Virginia Henderson (1955)
Dorothy Johnson (1968)
Martha Rogers (1970)
Dorothea Orem (1971)
Betty Neumann (1972)
Sister Callista Roy (1976)
Jean Watson (1979)
Rosemarie Parse (1987)
Patricia Benner and Judith
Wrubel (1989)
GOAL OF NURSING
To help patients gain independence in
meeting their needs as quickly as pos-
sible
To reduce stress, allowing the patient to
recover as quickly as possible
To achieve maximum level of wellness
To care for and help patients with various
needs attain self-care
To help individuals, families, and groups
attain and maintain maximum levels
of total wellness through purposeful
interventions
To identify types of demands placed on
the patient and the patient’s adaptation
to them
To promote health, restore patients to
health, and prevent illness
To assist the patient in interaction with the
environment and in co-creating health.
To sustain a safe and protective environ-
ment
To care about the patient as an individual
PRACTICE FRAMEWORK
Fourteen fundamental needs
Seven behavioral subsystems in an adaptation
model
Concept of “unitary man” evolving along the life
process
Self-care deicits
Systems model with stress reduction as its goal;
nursing care occurs on various levels: primary
prevention, secondary prevention, or tertiary
prevention
Four adaptive modes: physiologic, psychological,
sociological, and independence
“Carative” factors, with caring as an interpersonal
process used to meet human needs
Human becoming: patients are open, mutual,
and constantly interacting with the environ-
ment. Health is constantly changing
Primacy of caring: caring is central and allows for
the giving and receiving of help. Caring extends
to all aspects of care of the patient

patient care. Question the way things are done for patient
care, and ask what does not make sense or what needs clari-
ication. Ask yourself, Is there a better way to perform this
procedure? An example of such a question would be, Is this
the best solution to use for mouth care for this patient un-
dergoing chemotherapy? Research the question topic and
gather the best evidence available for an answer to the ques-
tion. Critically look at the research for signs of validity of the
data. Integrate the best evidence with your clinical expertise.
Consider the patient’s preferences and values when decid-
ing on a course of action. Evaluate the outcome of the new
action(s). Resources for research and guidelines for evidence-
based practice include evidence-based journals, systematic
reviews of studies, centers for evidence-based nursing, and
evidence-based practice guidelines. A list of resources for
evidence-based nursing is available from Virginia Common-
wealth University at http://guides.library.vcu.edu/ebpsteps.
A tutorial on understanding evidence-based practice is avail-
able at that website.
Evidence-based nursing is used to help determine
“best practices.” “Best practice means the use of
care concepts, interventions, and techniques that are
grounded in research and known to promote higher
quality of care and living” (University of Iowa College
of Nursing, 2015a, 2015b). Clinical ield experience
and evidence-based research are used to establish the
best practices for patient care. Best practices are often
provided in the form of clinical practice guidelines.
Best Research
Evidence
EBP
Professional Patient
Nursing Values
Expertise
FIGURE 1.6 Evidence-based nursing.
Clinical practice guidelines are the product of evidence-
based research, and they serve as a way for nurses to
implement the evidence-based practices. For example,
instead of performing catheter care a certain way
“because we’ve always done it this way,” the nursing
staff adheres to a speciic guideline that is evidence-
based—has been shown with scientiic evidence—to
be safer and more effective. To sum up, evidence-based
nursing is where the best research evidence, patient val-
ues and preferences, and professional nursing expertise
come together (Fig. 1.6).
Think Critically
Which role of the nurse appeals to you the most?
6 UNIT I Introduction to Nursing and the Health Care System
Box 1.1 Standards of Practice for the Licensed Practical/Vocational Nurse
Practice
The licensed practical/vocational nurse:
1. Shall accept assigned responsibilities as an accountable
member of the health care team.
2. Shall function within the limits of educational preparation
and experience as related to the assigned duties.
3. Shall function with other members of the health care
team in promoting and maintaining health, preventing
disease and disability, caring for and rehabilitating indi-
viduals who are experiencing an altered health state, and
contributing to the ultimate quality of life until death.
4. Shall know and utilize the nursing process in planning,
implementing, and evaluating health services and nursing
care for the individual patient or group.
a. Planning: the planning of nursing includes:
1) assessment/data collection of health status of
the individual patient, the family, and community
groups
2) reporting information gained from assessment/
data collection
3) the identiication of health goals
b. Implementation: The plan for nursing care is put into
practice to achieve the stated goals and includes:
1) observing, recording, and reporting signiicant
changes, which require intervention or different goals
2) applying nursing knowledge and skills to promote
and maintain health, to prevent disease and
CURRENT NURSING PRACTICE
As nursing has grown and changed to meet the needs
of society, laws have been made and standards set
that govern the practice of the profession. In 2015, the
American Nurses Association (ANA) revised the Stan-
dards of Nursing Practice, which contains 17 standards
of national practice of nursing, describing all facets of
nursing practice: who, what, when, where, and how.
These standards for the professional RN protect the
nurse, the patient, and the health care agency where
nursing care is given. Additionally, the ANA revised
and updated the Code of Ethics for Nurses with Interpretive
Statements, including areas addressing social media,
the importance of intra-professional collaboration,
and consideration of social justice (Epstein & Turner,
2015). The National League for Nursing published a
vision statement describing the practical nurse’s role
in advancing the nation’s health, emphasizing the
importance of the practical nurse’s contribution as
professional partners in the health care team (National
League for Nursing, 2014). The practical nurse fol-
lows standards written by the National Federation of
Licensed Practical Nurses to deliver safe, knowledge-
able nursing care (Box 1.1, Appendix B). The National
Association for Practical Nurse Education and Service
(NAPNES) has formulated an additional set of stan-
dards for practical nurses (see Chapter 3). In Canada, a
set of similar standards guides the practice of nursing.
Nurse practice acts have been established in each of
disability, and to optimize functional capabilities of
an individual patient
3) assisting the patient and family with activities
of daily living and encouraging self-care as
appropriate
4) carrying out therapeutic regimens and protocols
prescribed by personnel pursuant to authorized
state law
c. Evaluations: The plan for nursing care and its
implementations are evaluated to measure the
progress toward the stated goals and will include
appropriate persons and/or groups to determine:
1) the relevancy of current goals in relation to the
progress of the individual patient
2) the involvement of the recipients of care in the
evaluation process
3) the quality of the nursing action in the implementa-
tion of the plan
4) a re-ordering of priorities or new goal setting in the
care plan
5. Shall participate in peer review and other evaluation
processes.
6. Shall participate in the development of policies
concerning the health and nursing needs of society and
in the roles and functions of the LP/VN.
the US states and in the provinces of Canada to regu-
late the practice of nursing. Each state has a regulatory
body that makes and enforces rules and regulations
for the nursing profession. The practice acts generally
deine activities in which nurses may engage, state the
legal requirements and titles for nursing licensure, and
establish the education needed for licensure. The prac-
tice acts are designed to protect the public, and they
deine the legal scope of practice. Policy and proce-
dure books are established by each facility that hires
nurses. These books deine which procedures each
professional can perform in that facility and specify
step-by-step guidelines for the way that facility wants
a procedure performed.
The National Council of State Boards of Nursing
(NCSBN) has a proposal to enact rules for transition
to practice for all newly licensed nurses. All newly
licensed nurses will be required to complete a transi-
tion to practice program that meets the board criteria
if the rule becomes a criterion for license renewal. The
program would involve a minimum 6-month precep-
torship with ongoing support through the irst year of
practice.
The nursing process emerged during the 1970s and
1980s as an organized, deliberate, systematic way to
deliver nursing care. The nursing process provides a
way to implement (to put into action) caregiving, and
it combines the science and the art of nursing. The
nurse focuses on the patient as an individual, identiies

FIGURE 1.7 Students in modern day simulation lab.
health care needs and strengths of the patient, estab-
lishes and implements a plan of action to meet those
needs, and evaluates the outcomes of the plan. It is a
circular process involving ongoing assessment, nurs-
ing diagnosis, planning, implementation, and evalua-
tion. The nursing process is presented in depth in Unit
II: The Nursing Process.
NURSING EDUCATION PATHWAYS
Formal education has been another way to build a pro-
fessional image for nursing. Nursing education has
been mostly moved from hospital training schools into
institutions of higher learning. There are two levels
of entry into nursing: practical (or vocational) nurs-
ing and registered nursing. Often a student studies to
become a certiied nursing assistant before going up
the “ladder” to practical/vocational training. Each
educational program produces graduates with skills
for a particular level of entry into practice. A nursing
assistant program is short, averaging 6 to 8 weeks. Ba-
sic personal care and basic nursing skills are taught.
The practical nursing program generally takes 12 to 18
months to complete. The registered nursing program
(RN) requires 2 to 5 years of education, depending
on the type of degree sought (Fig. 1.7). If the student
has already obtained a practical/vocational nursing
license, the program may require only 1 more year to
become an RN.
PRACTICAL NURSING
Practical nursing was created to ill a gap left by nurses
who enlisted in the military services during World War
II. Programs were developed to train practical nurses
to care for well people and those who were mildly or
chronically ill or past the acute stage of illness. RNs
could then concentrate on the acutely ill. A need for
Nursing and the Health Care System CHAPTER 1 7
Advanced Practice Nurse
PhD
Nurse Practitioner
Nurse Anesthetist
Clinical Nurse Specialist
Nurse-Midwife
MSN
Registered Nurse
Baccalaureate
Associate Degree
Diploma
Practical/Vocational Nurse
Certified Nursing Assistant
FIGURE 1.8 Nursing education ladder.
practical nurses continued after the war, and NAPNES
was formed to standardize practical nurse education
and to establish licensure criteria for graduates. Practi-
cal nursing programs are offered in vocational schools,
hospitals, proprietary schools, and community col-
leges. Graduates take the National Council Licensure
Examination for Practical Nurses (NCLEX-PN) after
program completion. Successfully passing the exami-
nation and obtaining licensure allows the use of the
initials LPN or LVN after one’s name. Practical nurses
provide direct patient care under the supervision of
an RN, advanced practice RN, physician assistant,
physician, dentist, or podiatrist. Many community
colleges have structured the practical nurse curricu-
lum so that graduates can easily enter the second year
of the registered nursing program. This type of curric-
ulum is considered a “ladder program.” Many LPN/
LVN programs require that the entering student be a
certiied nursing assistant (Fig. 1.8).
After completion of an LPN/LVN curriculum and/
or licensure, the graduate can seek certiication by
NAPNES in pharmacology, long-term care, and/or IV
therapy. The pharmacology examination can be taken
online. Each of the three certiications is valid for 3
years and can then be renewed.
REGISTERED NURSING
Graduates of three different educational programs
are qualiied to take the RN licensure examination
(NCLEX-RN): a hospital-based diploma program, a
2-year associate degree program at a community col-
lege, or a 4-year baccalaureate nursing program at a
college or university. RNs may provide bedside care or
care in the community or supervise others in manag-
ing care of multiple patients.
Diploma schools continue to decrease as the desire
to improve the professional image of nursing through
8 UNIT I Introduction to Nursing and the Health Care System
more formal education occurs and many diploma pro-
grams have been dissolved or absorbed into college-
or university-based educational systems because of
mergers. Hospitals could no longer afford to provide
the expensive diploma programs. Diploma nurses are
more extensively trained in skills compared with the
students of other programs. They spend a far greater
number of clinical hours working directly with patients,
but they do not get as broad a base of scientiic knowl-
edge as college-educated nurses receive. Fewer than
10% of RN programs are diploma programs.
Associate degree programs attract the majority of
RN students. The associate degree nurse is considered
a technical nurse and is not speciically prepared to
work in a management position, although many do.
Graduates of these programs have 2 years of clinical
experience along with their academic classes.
Baccalaureate nursing programs prepare nurses
who have managerial skills, as well as bedside nurs-
ing skills. The push toward professionalism, uniica-
tion, and higher educational standards/consistencies
for nursing has caused the ANA to propose that the
baccalaureate degree be necessary for entry into pro-
fessional nursing practice. There has been consider-
able controversy over this proposal because the many
RNs who graduated from diploma or associate degree
programs believe that their jobs may be threatened by
such a proposal. To date, only some employers distin-
guish among the various educational programs of the
RN. Magnet hospitals require that 100% of the nursing
managers hold a Bachelor of Science in nursing degree
(BSN), and although they make no speciic recommen-
dation for staff nurses, the typical hospital with Mag-
net designation tends to have about half of employed
bedside RNs holding a BSN degree (Hawkins & Shell,
2012). In most facilities, however, graduates of all three
RN programs are viewed the same. Another concern
is that, if the more expensive and longer program
were required to become a professional RN, employ-
ers would have to pay higher salaries. Differentiation
of salaries based on educational degree primarily oc-
curs only at the managerial level, not the bedside level.
The nursing shortage tempered the push for all nurses
to be baccalaureate prepared because the program is
twice as long, but the ANA is again pressing for the
BSN to be required for entry into RN practice.
Think Critically
What are three educational differences between the practical
nurse and the RN?
ADVANCED PRACTICE NURSING
Graduate programs are available in nursing for both
master’s and doctorate degrees. Nurses who pursue
higher education are prepared as specialists in the
various clinical branches of nursing, in research, or in
administration. Another form of advanced education
is the nurse practitioner program. RNs continue their
training in a specialty such as family practice, pediat-
rics, maternity, psychiatry, adult health nursing, acute
care, or geriatrics; once licensed, they can practice more
independently than as an RN. Nurse practitioners
(NPs) provide care in a hospital, outpatient, ambula-
tory care, or community-based setting. In many states,
they can treat patients on their own and write prescrip-
tions under the direction of a physician. NPs are one of
the four types of advanced practice nurse. The other
three include the titles certiied nurse-midwife (CNM),
certiied registered nurse anesthetist (CRNA), and
clinical nurse specialist (CNS). Each type of advance
practice RN requires speciic certiication and training.
The ANA set up a separate American Nurses Cre-
dentialing Center to enhance the professional image of
nursing. RNs who have experience in a particular spe-
cialty may take a comprehensive examination. Passing
the examination provides the nurse with certiication
of expertise in that specialty. Certiication is also avail-
able for the practical nurse under a program devel-
oped by NAPNES.
DELIVERY OF NURSING CARE
Various systems of delivering nursing care have been
tried through the years. Today various adaptations
are devised to meet the speciic needs of the patients
and nurses. Functional nursing care was the irst
care delivery system for the practical nurse. Practical
nurses performed a series of tasks such as adminis-
tration of medication and treatments. Care was rath-
er fragmented; however, it was cost effective. Team
nursing evolved in the 1950s and extended into the
mid-1970s. An RN was the team leader who coordi-
nated care for a group of patients. Work tasks were
assigned to the other members of the team, the practi-
cal nurses and the nurses’ aides. This system worked
fairly well as long as there was excellent communica-
tion among the members and the team leader evalu-
ated care delivered. Total patient care came next, in
which one nurse carried out all nursing functions for
the patient, including medication administration.
This was an effort to provide less fragmented care
for the patient. Of course, total patient care is more
expensive.
Primary nursing appeared in the late 1960s and
1970s. In this system, one nurse plans and directs care
for a patient over a 24-hour period. This method elimi-
nated fragmentation of care between shifts. When the
primary nurse is off duty, an associate nurse takes over
the care and planning. Today, primary nursing is of-
ten modiied with the use of cross-trained personnel
assigned to help with duties. To increase the level of
productivity, ancillary workers supervised by the RN
are trained in multiple functions, such as clerical and
housekeeping tasks, vital sign measurement, and phle-
botomy. This system has not been entirely satisfactory.

Currently, because research is showing better patient
outcomes with more of the care being delivered by
nurses, there is a trend back to total patient care.
Relationship-based care appeared in the early 2000s
(Koloroutis et al., 2004). It emphasizes three critical re-
lationships: (1) the relationship between caregivers and
the patients and families they serve; (2) the caregiver’s
relationship with him- or herself; and (3) the relation-
ship among health team members (UCLA Department
of Nursing, 2015). The motivation behind relationship-
based care was to promote a cultural transformation
by improving relationships to foster care for the patient.
Some schools of nursing have adopted relationship-
based care as the foundation of their nursing education
curriculum.
Patient-centered care has been described since
the 1950s, but it came to the forefront in 2001 when
the Institute of Medicine (IOM) targeted six areas for
improvement in the US health care system, including
safety, effectiveness, patient-centeredness, timeliness,
eficiency, and equitableness (Cliff, 2012). Patient-
centered care has been fully embraced by the nursing
community, and it is identiied as one of the seven
QSEN competencies (QSEN.org, 2015).
PRACTICE SETTINGS
Practical nurses work in health care organizations un-
der the supervision of an RN, advanced practice RN,
physician assistant, physician, dentist, or podiatrist.
Traditionally, many LPN/LVN positions were found
in the hospital setting, whereas community nursing,
school nursing, and public health nursing were pri-
marily the arena of the professional RN. Recent trends
have changed, however, and expanded the employ-
ment landscape for the practical nurse. Hospitals now
tend to hire primarily RNs, yet practice settings for the
LPN/LVN remain plentiful and include the following
health care organizations:
• Hospitals: Restorative care is provided to ill or in-
jured patients.
• Subacute and extended care facilities: In facilities
for subacute, intermediate, or long-term care; per-
sonal care and skilled care are provided for those
requiring rehabilitation or custodial care.
• Assisted-living facilities: In facilities that provide
housekeeping, prepared meals, and varying de-
grees of nursing care.
• Physicians’ ofices: Ambulatory patients receive
preventive care or treatment of an illness or injury.
• Ambulatory clinics: Ambulatory patients come for
preventive care or treatment of an illness or injury;
often treatment by specialty groups is available on
site. Numerous specialty clinics that employ LPNs/
LVNs include cardiology, dermatology, allergy, im-
munology, pulmonology, and many others.
• Renal dialysis centers: Patients with kidney failure
receive renal dialysis treatments.
Nursing and the Health Care System CHAPTER 1 9
FIGURE 1.9 Home health nursing. (Photo copyright istock.com.)
• Hospice and palliative home care: Supportive treat-
ment is provided for patients who are terminally ill,
improving quality of life and ease of suffering.
• Home health agencies: In-home care is provided to
patients by nurses who visit the home (Fig. 1.9).
• Neighborhood emergency centers/urgent care
clinics: Minor emergency care is provided to pa-
tients within the community setting.
• Correctional facilities: Care is rendered to incarcer-
ated individuals, assisting with physical examina-
tions, administering medications, and performing
medical treatments.
• School nurse: Triage, medication administration,
irst aid, and some care of students with diabetes.
• Surgical centers: These centers perform same day
surgeries on typically healthier individuals than those
found in a typical hospital operating room (OR). The
LPN/LVN is often employed as the preoperative
nurse in this setting.
As the role of the practical nurse expands, employ-
ment in other practice settings is possible.
TODAY’S HEALTH CARE SYSTEM
In times past, most medical care was provided by phy-
sicians in private practice. With the technological ad-
vances in medicine and the lood of new drugs on the
market, health care costs have risen dramatically. Al-
though the use of magnetic resonance imaging (MRI)
and computed tomography (CT) provides much more
data than a standard radiograph dose, both are very
expensive. Microsurgical techniques allow procedures
that would not have been possible 40 years ago. Older
adults are living longer and needing more years of
medical care and numerous prescription drugs.
Diagnosis-related groups (DRGs) were created by
Medicare in 1983 as an attempt to contain rising health
care costs. The DRG system means that a hospital
receives a set amount of money for a patient who is
hospitalized with a certain diagnosis. If a patient is
admitted with pneumonia, only a certain number of
days of hospitalization are allowed and will be paid for
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN