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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient Care511
Specific Patient Health Problems520

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

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

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

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

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

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

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

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

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

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

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

Contents xxv
Chapter 16 Older Adult Patients809

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Professional Caring
1. Certification is a process by which a nongovernmental agency, using predetermined
standards, validates an individual nurse’s qualification and knowledge for practice
in a defined functional or clinical area of nursing.
2. A common goal of specialty certification programs is to promote consumer
protection and to promote high standards of practice.
3. The certified nurse may be held to a higher standard of practice in the specialty
than the noncertified nurse; certification validates the nurse’s knowledge in a
1
specialty area.
4. Critical care certifications are awarded by AACN Certification Corporation,
established in 1975. AACN Certification Corporation is accredited by the National
Commission for Certifying Agencies, the accreditation arm of the National
Organization for Competency Assurance.
a. The AACN Certification Corporation develops and administers the CCRN, CCRN-E,
CCRN-K, PCCN, ACNPC, ACNPC-AG, CCNS, ACCNS-AG, ACCNS-P, and
ACCNS-N specialty examinations, and the CMC and CSC subspecialty examinations.
b. CCRN certification: Separate certification processes for critical care nurses
practicing with neonatal, pediatric, or adult populations.
c. CCNS certification: Advanced practice certification of nurses in acute care clinical
nurse specialist practice. Separate certification processes for CNSs practicing with
neonatal, pediatric, or adult populations.
d. ACNPC and ACNP-AG certification: Advanced practice certification of acute care
nurse practitioners. Separate certification processes for ACNPs practicing with adult
and adult-geriatric populations.
5. Certification provides patients and families with validation that the nurses caring
for them have demonstrated knowledge that exceeds that which is assessed in entry-
level licensure examinations (AACN Certification Corporation, 2020a,b,c).
a. Certification has been linked to patient safety.
b. Units with higher numbers of certified nurses reported lower frequency of falls or
pressure ulcer development.
c. Certification has also been linked to patient satisfaction, from both patients’ reports
and nurses’ perceptions.
PROFESSIONAL LIABILITY
1. Professional negligence: An unintentional act or omission. It is the failure to do
what the reasonable prudent nurse would do under similar circumstances, or an
act or failure to act that leads to an injury of another. Six specific elements are
necessary for professional negligence action and must be established by a person
bringing a suit against a nurse (plaintiff):
a. Duty: To protect the patient from an unreasonable risk of harm.
b. Breach of duty: Failure by a nurse to do what a reasonable prudent nurse would do
under the same or similar circumstances. The breach of duty is a failure to perform
within the given standard of care. The standard defines the nurse’s duty to the patient.
c. Proximate cause: Proof that the harm caused was foreseeable and that the person
injured was foreseeably a victim. This element can determine the extent of damages
for which a nurse may be held liable.
d. Injury: The harm done.
e. Direct cause of injury: Proof that the nurse’s conduct was the cause of or contributed
to the injury to the patient.
f. Damages: Proof of actual loss, damage, pain, or suffering caused by the nurse’s conduct.
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conviction, painted a new and another Jacob. She was aware that the whole
world set sternly against him and, misreading the attempted murder,
suspected that, perhaps, even Adam Winter might not have forgiven him.
Surely it must have been some fiery word from Adam that prompted
Samuel to his attempt. Yet there she hesitated and, on second thoughts,
remembered Adam better. Doubtless he had pardoned long ago; but mad
Samuel none the less echoed the people, and she knew, from what her father
had told her, that the country side was more interested in Jacob's disaster
than regretful of it. Their sole regret went out for the brother and the aunt of
the man responsible.
Now, despondent and bewildered, Margery found some comfort in

talking openly to her brother and his wife.
She took tea with them on a Sunday and was unguarded and indifferent
as to what they might say, or think, of her opinion. They perceived the
change in her and set it down to Jacob's situation; but though that had
largely served to stimulate Margery and offer a point for argument with her
parents, it did not account for the radical and growing operations of her
soul. The inevitable had happened, and with all its sorrows and trials, she
yet wanted back her life as it was, sanctified to her by custom. She yearned
for the home that she had made and her spirit could rise to no other. She
was changed, weakened a little mentally, as well as much physically, by her
experiences, more frightened of life and less desirous to face it. Now she
longed only for quiet—to be secluded and hidden away, forgotten and left
alone. She did not dread solitude, silence, peace any more. She desired
them before all things and wearied inexpressibly of the noise of the street,
the bustle of business and the din of activity round about her. Among the
many facts learned with increasing certainty, was the assurance that she
would soon sicken and die, cooped here under the eyes of her parents—an
object of pity for her father, of triumph for Judith.
These convictions she voiced to Jane, and whimsically lamented that

situation which all just persons supposed she was most thankful to have
escaped for ever.
"Time blots out the bad and leaves the good still to remind you," she
said. "You may not believe it, but it is so. I always remember the happy
things and slip the unhappy. It's not only things that happen, but people that
made them happen. Get far enough away from people, and you find the
parts in them you hate grow dimmer and the parts you like grow brighter.
That's why the natural feeling is to speak kindly of the dead. We generally
feel kindly to them. At least I do."
"It's true," declared Jane. "When anybody's dead, part of 'em always
rises up again on people's tongues, and we don't speak well of them who are
dead only because they are dead and can't defend themselves, but because
time, as you say, Margery, keeps the good and lets the bad go. I can say it to
you and Jeremy, though I wouldn't to anybody else. Take your own mother.
I always feel ever so much kinder to her when I escape from hearing her, or
seeing her for a week or so."
"You oughtn't to say that, Jane," declared her husband. "It's a very
doubtful speech."
"Not it," she answered. "No use pretending. You don't see your mother
like the rest of the world, because she don't see you like the rest of the
world. And Margery's right. If she don't know, who should?"
"Ask yourself, Jane. You're married and have got plenty of sense to see
things. Suppose Jeremy and you was parted for some great, terrible deed
done by him: a bee in Jeremy's bonnet, for which he was sorry enough. And
suppose, with time, you hadn't only forgiven him, as a Christian, but really
and truly, as a wife and a woman. And suppose everything—everything that
had made your life, and that you'd made of your life, was taken away, and
you were left stranded. What would it be to you?"
"Hell," said Jane frankly. "There's no other word for it."
"And what would you do, Jeremy, if that had happened to you?"
continued his sister. "Would you feel that, for her soul's sake, Jane must
never come back to you?"
"I'm glad to say no such thing could happen to me, and it's idle worrying
to think what you'd do if a thing happened that can't happen," answered the
man. "And now you're here, it will be good for you to get away from your
own vexations for a bit and lend a hand with mine. And first I may tell you
that I've seen your husband that was."
"Seen him? Oh, Jeremy!"
"Keep it dark. I didn't seek him. He cornered me and would talk. Don't
think I yielded about it. Not at all. I was firm as a rock with him, because,
of course, mother's dead right in that matter; but there it is. Jacob Bullstone
was very wishful indeed to get into touch with you, and seemed to think he
had a right. But I hit out from the shoulder fearlessly, and he heard my
honest opinion of him and so on. However, I'm a man of the world
notwithstanding, and nobody knows how difficult the world is better than I
do. So up to a certain point and, well within my conscience, I may do as I'm
done by in the matter."
Margery regarded him with parted lips.
"He wants to see me?"
"I was the last to have speech with him before he was smashed, and
there's no doubt he had a near squeak of his life. I remember Amelia Winter
telling me years ago, when I was a huckster, that in the case of Samuel
Winter, as a young child, it was a great question whether he'd turn out
amazingly clever, or weak in his head. Unfortunately he proved one of the
Lord's own, and now, since this business, Adam feels it a difficult question
whether Sammy didn't ought to be put away. Why I tell you this is because
I'm coming to the point, and that is our mother's fine rule of life that nothing
happens by chance."
"Go on," said Margery.
"Well, granted nothing happens by chance, then we've got the

satisfaction of knowing we are doing Heaven's will from morning till night.
Therefore, if you help me in a vital matter and I help you in a vital matter,
we're both doing Heaven's will; and whatever came of it, mother would be
the first to confess it was so."
"Lord, Jeremy!" cried Jane. "D'you mean to say——"

"I mustn't come into it," explained Jeremy. "I don't say I'll lift a hand;
but I do say that, if it was established that Jane and I go to the post-office
when the old people retire, I should feel a great deal clearer in my mind and
kinder to the world at large. It is high time I had a bit of light on that
subject, and I'm a good deal puzzled the light hasn't shone. I've been hoping
a long time to hear we was to go in, and so I feel that you might find good
and useful work ready to your hand in that matter, Margery. And—and one
good turn deserves another. That's well within a clear conscience."
"A 'good' turn—yes," declared Jane doubtfully.
"It would be a good turn if I decide to help Margery, because we must

all do as the Lord intends, and therefore it couldn't be a bad one," explained
the casuist. "In a word, if Margery impressed upon mother that the right and
proper thing was to trust the business and the post-office to us, that might
determine the point. As a matter of fact I'm uneasy. Father's been into
Plymouth more than once of late and, of course, they're looking ahead.
They always do."
"They are," answered Margery, "and I'll tell you something. Mother
wants you and Jane to take over the business—under father. And father,
seeing you've never stuck to nothing in your life, feels very doubtful if
you're the man. They differ."
"Just as I thought," murmured Jeremy, "and some people might be

vexed with their fathers; but that's only to waste time. So there it is. You're
all powerful with father—eh, Margery?—and surely to God you know Jane
and me well enough to know mother is right."
Margery perceived the nature of the bargain. She believed with Jeremy
that their father was to be won. Indeed he sometimes came near yielding to
Judith's steadfast conviction. She might very possibly settle the point in her
brother's favour; but what could he do for her? Nothing with her parents.
The problems that had looked vague and, indeed, had never been
considered in her mind before, now rose and began to take a definite shape,
Until now nothing but a dim, undefined desire for something that must not
be—for something her parents held unthinkable—had stolen through her
mind and settled over it, like a sad fog. She had accepted the situation and
supposed that the craving for some return to vanished conditions was at best
weakness, at worst evil. Yet now she had moved beyond that point to an
acute nostalgia. Jacob's tribulation was augmented by the startling news that
he desired to see her. She found comfort in Jeremy's sophistries, but knew,
even while he uttered them in his mother's words, that they echoed anything
but his mother's spirit. Jeremy was a humbug, as charming people are so apt
to be; but the fact still remained: nothing happened but what Providence
planned.
She began to think of details and they made her giddy. To move from
secret wishes to open words was enough for one day. She had never dared
to be so explicit, and her confession in the ear of sympathetic Jane
comforted her. But her constitutional timidity, developed much of late, now
drew her in.
What could Jeremy do? Deeds were not in Jeremy's line. Time must
pass. Jacob must get well again—then, perhaps—she would see how she
felt then. He might change his mind. Possibly he only wanted to mention
some trifle. Margery doubted whether her present emotions were healthy or
dangerous; then she fell back on her brother's affairs.
"You've given me something to think about; and I will think of it," she
said.
"And Jeremy shall think of what you've told us," promised Jane, "for I'll
remind him to do so."
"The thing is the greatest good to the greatest number," declared Jeremy.
"That's always been my rule and always will be. And clearly the greatest
good to me and my wife and children lies at the post-office. Others see it
beside us. As for your greatest good, Margery—that's a very difficult
question."
"I know it. I hope I haven't said too much; but you'll forgive me if I
have. I feel—I feel, somehow, that I ought to see my husband, if he still
wishes it."
"You would," answered Jane, "and so would any nice woman feel the
same."
"That's the point," argued Jeremy. "You may be right, or you may be
wrong. But the general opinion is that you show what a fine creature you
are by keeping away from him. Why don't you put it to mother?"
"Put it to a man," advised Jane. "Ax parson. It's a free country and
though we're all Chosen Fews, that don't prevent parson from being a very
sensible chap. Or, if you don't like the thought of him, try somebody else."
But Margery gave no promise. She went home vaguely heartened and
determined at least to work for Jeremy. She felt, indeed, that what he
desired would be sure to happen presently without any word from her; still
to work for him was good. She had nobody to work for now.
Next morning she went to chapel with Mrs. Huxam and, finding herself
brave afterwards, actually followed Jeremy's suggestion and gave Judith a
shock of unexpected pain.
"Mother," she said. "I've got great thoughts and you should hear them.
We can't think anything we're not meant to think, and now my thoughts
have taken a turn. You know how it was with me. After our trouble I didn't
want to live; I'd have been glad to shut my eyes and sleep and never wake
up. Then I got better and braver. And then I grew to miss the life of my
home terribly, because, whatever the cause, to be wrenched out of the little
holding of your days must hurt. And so I got worse again—body and mind.
And now I've looked on and asked myself about it."
"Better you looked still farther on and put away all that joins you to the
past. That I've told you more than once, Margery."
"You have; but I can't do it. You can't forget your whole married life and
your motherhood and the father of your children. If you do, there's nothing
left for a woman. And I've come to see this very clearly. I'm Jacob's wife."
"No longer in the Lord's sight."

"Let me speak. I'm Jacob's wife; and what I'm sure now is that Jacob is
a very different man from what he was. God Almighty has changed Jacob,
and the poison that did these dreadful things is poured out, and he's left, like
the man from whom the devil was drawn by Jesus Christ. Mother, when
first I even thought about Red House, I felt shame and dursn't tell you, for I
feared the longing to see it again came from the devil. Now I don't feel
shame, and I know the longing don't come from the devil. There's duty to be
done there yet."
"Thank God you've told me this," answered Judith, "for we've got to do
some fierce fighting, I fear. Not the devil? Why, I see his claws, Margery!
"'Tis his last and deadliest stroke, to make his temptation look like duty
and come before you clothed like an angel of light. An old trick that's
snapped many a soul. Never, never do you hide your thoughts from me,
Margery, after this."
"But wait. Suppose, by forgiving in act as well as heart, I went back

presently. Then I might save Jacob himself."
"Oh, the cunning of the Enemy—the craft—the sleepless cleverness!

No, you can't save Jacob Bullstone; but you can lose yourself. There's
always the chance of losing yourself while breath is in your body, and
Lucifer knows it, and he'll often win at the last gasp on a man's deathbed.
He's proud, remember, and his pride leads him to try the difficult things.
Can't you see? How is it so few can see the net he weaves, while the lotion
of the Gospel's at everybody's hand to wash their eyes clear if they would?
He's vain as a peacock and likes to do the difficult things and catch the
souls in sight of Heaven's gates. I know; I read him; not many women have
conned over his ways like I have. And now he's saying 'Jacob Bullstone is
mine—a gift from his youth up—and there's no cleverness in keeping your
own; but the woman he's cast down is not mine.' And your soul would be
worth the winning. And what's cleverer than to make you think you can
save your doomed husband's soul when, to try, would be to lose your own?
You'd best to pray on your knees about this and call loudly on your Saviour.
I'm a lot put about to hear of such dreadful thoughts. They've crept in
through the chinks in the armour of salvation, Margery, and you must look
to it this instant moment."
"There's a human side, mother. The man has been called to face death.
He lies there in hospital and——"
"And where did he fling you to lie? Where was hospital for the ills you
have suffered and the death you have died? There is a human side, and to
return good for evil is our duty; but there's a higher duty than that. Don't
argue. I know all about the human side; but humanity was never yet called
upon to risk its immortality and hope of salvation. I'll hear no more
touching this at all, Margery. I'm suffering for you a good bit. I've failed to
make the truth clear seemingly."
"No, no, you haven't failed. I know how you view it."
"Set your trust where only trust can be set," said Mrs. Huxam, "and trust
your God, like a little child, to show you, in His good time, how your future
life's got to go. And first He wills for you to get up your health of mind and
body. Your mind before everything. Your body's nought; but your mind's
sick—far, far sicker than I thought—and we must see to it. There's fighting
to be done and we'll fight. I thought all that was over; but the devil smells a
sick soul, like a cat smells fish, and I might have known there was danger
lurking."
They returned home, to find that somebody had called upon Margery's
mother. Old William Marydrew awaited them in his Sunday black.
Margery he welcomed kindly, though she responded in doubt; but Mrs.

Huxam, who knew the ancient man for her son-in-law's friend, showed
open suspicion and seemed little inclined to grant the speech he begged.
"I've no quarrel with you," she said, "and I very well remember your
godly daughter, for Mercy Marydrew had the light; but——"
"The better the day the better the deed," ventured Billy. "Don't stand
against me till you've heard me. I don't come from Mr. Bullstone. I'm here
on my own—for a friendly tell—and I hope you'll respect my age and give
ear to what I'd like to say."
Mr. Huxam, who had been talking to William until his wife's return,
supported the proposition.
"Hear him, Judy," he said. "Nobody's ever heard nothing from William
that he shouldn't hear, but on the contrary, much that was well worth
hearing. Wisdom like his, when it's mellow and not turned sour, as wisdom
will with some old folk, be all to the good. We'll go into the kitchen and see
after dinner and leave you to it."
He departed with Margery, and Mrs. Huxam took off her black thread
gloves and blew her nose.
"Speak then," she said, "and take the easy-chair. I'm not one to deny
respect and attention to any religious-minded man; but I warn you that there
are some things don't admit of dragging up. You understand."
William plunged at once into the great matter of his visit.
"Single-handed I come," he said, "and I wish I was cleverer and better

skilled to bend speech to my purpose; but you must allow for that. In a
word, there's a general feeling in a good few minds that Jacob Bullstone is
indecent and blameworthy to want his wife to go back to him; while,
against that, in a good few other, well-meaning minds—women as well as
men—there's a feeling it might be a very decent thing to happen, and
wouldn't hasten the end of the world anyway. And I, for one, incline to
think the same."
"The end of the world's not our business," said Judith, "but the souls of
ourselves and our children and grand-children are our business. You strike
in on ground where I've just been treading, and I'm very sorry to hear you
can say what you have said. Whether it's indecent and blameworthy for
Jacob Bullstone to want his wife don't matter at all. What those doomed to
eternal death want, or don't want, is nought. But we've got to think of the
living, and we've got to save the souls that are still open to be saved."
"Certainly; and who, under God, has the right to damn woman, or child,
or man, or mouse, my dear? I saw Bullstone in hospital yesterday, and
seeing and hearing him, it came over me like a flame of fire to have a word
with you, because well I know you are the turning point—the angel of life,
or death I might say—to these two. Everything depends upon you
seemingly—or so he reckons. You hold their future lives in your hand.
That's a lot to say, but not too much. And I should much like to hear your
point of view on this high subject. Bullstone, I must tell you, have suffered
a very great deal, and his eyes are opened to his lunatic act. He was just as
mad every bit as Sammy Winter, who set the bull on him to mangle him.
Just as mad, my dear; but with a far worse sort of madness; and yet a
madness that can be cured, which Sammy's can't in this world. And afore
the God we both obey, I tell you that Jacob is cured. His sufferings have
been all you could wish, and his broken thigh, and so on, was nothing in
comparison. He's gone through tortures that make his broken bones no
worse than a cut finger; and I want you to understand that he's long ways
different from what he was, Mrs. Huxam, and an object for good Christian
forgiveness all round. And now you tell me what you think about it?"
Judith looked, almost with pity, at the ancient prattler. It seemed to her
that such people as Mr. Marydrew could hardly have more souls to save, or
lose, than a bird on a bough. They were apparently innocent and went
through the world, like unconscious creatures, doing neither harm nor good.
But Billy suddenly appeared in harmful guise. It was as though an amiable,
domestic animal had showed its teeth, threatened attack and became a
danger.
"You're touching subjects a thought too deep for your intellects, Mr.
Marydrew, if you'll excuse me for saying so," she began.
"Don't say that. I venture to think——"
"You think, but I know. I know that no man or woman can interfere
between Jacob Bullstone and his Maker, or undo what's done. For once
even the doubtful sense of the world at large sees it. A child could see it.
My daughter has come to the gate of salvation by a bitter road, like many
do. She's faced great sufferings and escaped awful perils; but she's through
the gate; it's fast home behind her, and she ain't going to open it again to her
death—be sure of that. He dares to want to see her, and you say he's
changed. But, after you've done some things, it's too late to change. He's
lost. Why? Because, like a lot of this generation, he's listened to false
teachers and thought the Powers of Evil were growing weak. To hear some
people, you'd think the devil was no more than a scarecrow set up to
frighten the world into the paths of goodness."
"True," admitted Billy. "It was so with me. Looking back I can plainly
see, as a lad, the fear of Old Nick had a lot more to do with my keeping
straight than love of God. God was above my highest imaginings. I only
knew He was wishful to get me into Heaven some day, if I gave Him half a
chance. But the devil seemed much nearer and much more of a live person.
Somehow you find that bad folk always are nearer and more alive than
good ones—don't you?"
"Because we all know bad people and have every chance to see them
misbehaving," said Mrs. Huxam, "but good people are rare, and always will
be."
"I wouldn't say that. I'm so hopeful that I rather share the growing
opinion against hell. I believe the next generation will knock the bottom out
of hell, my dear, because they'll find something better. There's a lot of
things far better than in my youth, and new love be better than ancient fear.
Grant that and you can't say Jacob's down and out. He's a very penitent
man, and he's turned to God most steadfast of late, and it would be a great
triumph for the mercy of God, his Maker, if he came through, and a great
sign of the Almighty's power in human hearts."
She regarded Billy with mild interest, but hardly concealed her
contempt.
"And you in sight of your grave and your judgment, and so wrong in
opinions," she said. "'A sign?' Yes. This generation seeks after a sign no
doubt; and that's an impious thing to do at any time. And I dare say the day
is not very far off when it will get the sign it deserves. D'you know what
you're doing, you perilous old man? You're trying to hold back the mills of
God—you, that know so little of the truth, that you can say the bottom's
going to be knocked out of hell! I didn't ought to listen, I reckon, for from
your own mouth you've told me you are with the fallen ones, and I never
thought the father of Mercy Marydrew had missed salvation. But 'tis a very
true thing that most of us are judged out of our mouths. No devil! Poor
soul! Poor, lost soul! But, such is the will of God, that I see clearer and
clearer how only them that have escaped Satan know him for what he is.
The world lies in his keeping, and the people don't know no more what has
caught them than the fish in a net. But I know. I see his ways and his awful
art. I see him as he is—black—black—and you can smell the smeech of
him when some people are talking. And not the swearers and lewd ones
only, but many, as think, like you, they are doing God's work. That's the last
and awfulest trick of him, William Marydrew—to make his work look like
God's."
Billy was amused and distracted from the object of his visit.
"My!" he said. "Blessed if I thought there was anybody in Brent knew

such a lot about Old Nick as you do, Mrs. Huxam. A proper witch doctor
you be! But even the saved make mistakes. 'Tis on the cards you may be
wrong, and I hope you are. You'm terrible high-minded, but them that want
to be high-minded must be single-minded, and the clever ones often come
to grief. You know a lot too much about the Black Man, and I'd like to hear
who told you. But be that as it may, there's a very fine thing called mercy—
come now."
"There is," said Mrs. Huxam, "or the bolt would fall a lot oftener than it
does. Mercy belongs to God, else heaven would be empty when the Trump
sounds; but there's also such a thing as justice, and justice is man's business.
He can leave mercy where it belongs and not dare to think of such a thing
when a sinner falls. For that's to know better than Him that made the sinner.
Justice is what we understand, because our Maker willed that we should.
Our first parents had their taste of justice, and justice is within our reach. To
talk of showing mercy to the wicked as you do, is to say a vain thing and
range yourself against justice. Only through justice can come hope for any
of us, William Marydrew. Our business is to do justly and not pander with
evil, or try to touch the thing with merciful hands."
"And that's what life have taught you," murmured Billy. "And you
thrive and keep pretty well on it. I've always heard you was a wonder, my
dear, but how wonderful I never did guess. Now tell me, is Adam Winter,
who be of the Chosen Few, in the right to forgive the man that did him so
much harm, or in the wrong?"
They talked for an hour, then, weary and conscious that Mrs. Huxam
was not made of material familiar to him, William rose and went his way.
"No offence given where none is taken, I hope. I'm sorry you can't see it
might be a vitty thing for husband and wife to come together in fulness of
time; because if you can't see it, it won't happen perhaps. But turn over the
thought, like the good woman you are, and if the Lord should say that
mercy ain't beyond human power, after all—well, listen."
"You needn't tell me to listen, Mr. Marydrew. I'm sorry for your
blindness and I'm sorry for your deafness, but I see clear and I hear clear
still."
"Good day then. No doubt it takes all sorts to make a world."
"Yes," answered she, "but only one sort to make a heaven."
He laughed genially.
"Then I hope they won't knock the bottom out of hell, after all, else
where should us of the common staple go? Must spend eternity
somewhere."
"Scratch a sinner and the devil always peeps out," thought Mrs. Huxam
as William departed.
CHAPTER VII
AT JACOB'S BEDSIDE
A week later William visited Jacob in hospital. He was nearing

recovery, but now knew that he might be lame for the rest of his life. The
sufferer felt indifferent; but he cherished minor grievances and grumbled to
his friend.
"Only Auna ever comes to see me. Would you believe that? Not once
has John Henry visited me, and only once, Avis—and her marriage, that I've
agreed to, and the farm that I've given her and all!" he said.
"Young lovers be selfish toads," explained William; "think nothing of it.

I believe Avis will prove a better daughter after marriage than before. She's
the sort will get sweeter with ripeness. For John Henry there's no excuse. I'll
talk to him some day and open his eyes. But the great truth is that their
amazing grandmother be more to your children than their own parents. A
mystery, Jacob; but the ways of blood are always a mystery. The dead will
come to live in their havage[1] and pass on the good and bad qualities alike.
'Tis a pity Providence don't look to it that only the good be handed down;
because then the breed of men and women would be a lot better by now
than they are; but all qualities are part and parcel, and even goodness often
takes narrowness and coldness of heart along with it."
[1] Havage—offspring.
"Margery's heart was never cold."
"But her mother's—her mother's, Jacob! I may tell you now that I
carried out a little plot in that quarter and went to see Mrs. Huxam on a
Sabbath. I had in my mind that at my great age and with my well-known
good character, I might influence her; because in a few other directions I've
talked round high-minded people and showed 'em that, as things are, nought
could be hopefuller than for you and your wife to come together again."
"You meant well as you always do, Billy."
"An Old Testament fashion of woman is your mother-in-law. The faith

that would move mountains. It's a good thing that she hasn't got much
power, for she'd use it in a very uncomfortable fashion if she had. A great,
mournful wonder in the land. She's like a sloe-bush, Jacob: the older she
grows, the sharper her thorns and the poorer her fruit. I came away with my
tail between my legs, I assure you. I was dust in the wind afore her."
"She'll never change."
"Never. Wild horses wouldn't make her change. Hell comforts her, same
as heaven comforts us, and there's no fear the fires would go out if she had
the stoking."
"The littleness of her—the littleness of her!" cried Jacob. "Can't she see
that all this talk is nothing to tortured flesh and blood? Her power lies in the
weakness and ignorance of other people. Hear this, William: my wife would
see me and listen to me, if her mother allowed it. And when I know that—to
Auna she whispered it—in a weak moment—still Auna heard—and when I
know that, what's hell or heaven to me? They must be nothing, anyway, to a
man who has done what I've done—to a man who has brought such sorrow
on the earth as I have. What is eternity to one who's wasted all his time?
The things I might have done—the happiness I might have given—the good
I might have wrought! Instead, I break the heart of the best, truest woman
ever a man had for wife. What can alter that? Can eternity alter it? Can
heaven make it better, or hell make it worse? Nothing can change it but
what happens here—here—before it's too late. And Judith Huxam is going
to confound all—just that one, old woman, poisoned by religion, as much as
I was poisoned by jealousy."
"A very great thought, Jacob," admitted Mr. Marydrew. "We be in the
hand of principalities and powers, and mystery hides our way, look where
we will. But we must trust. Everything is on the move, and the Lord can
touch the hardest heart."
"Hearts are nothing, William. The head governs the world, and great,
blind forces govern the head. Blind forces, driving on, driving over us, like
the wheel over the mole by night; and despite our wits and our power of
planning and looking ahead and counting the cost, we can't withstand them.
They run over us all."
"We can't withstand 'em; but the God who made 'em can," answered
William. "Be patient still and trust the turn of the lane. You be paying the
wages of your sin, Jacob; you be paying 'em very steady and regular; and I
hope that a time will come when you'll be held to have paid in full. We
never know how much, or how little our Maker calls us to pay for our
mistakes. You may have very near rubbed off the score by God's mercy; for
He's well known for a very generous creditor and never axes any man to
pay beyond his powers."
He chattered on and, from time to time, patted Jacob's big hand, that lay
on the counterpane of his bed.
The sick man thanked him presently and then there came Peter, to see
his father on business. He asked after Jacob's health and expressed
satisfaction to know that he was making progress. Having received
necessary instructions, he went his way and William praised him.
"There's more humanity in Peter than there is in my eldest," admitted

Peter's father.
He grew calmer before Billy left him and promised to keep his soul in
patience.
"First thing you've got to do is to get well and up on your legs again
against the wedding," urged William.
"I hope much from it," answered Jacob. "I'm planning to beg Barlow
Huxam to see me on the subject. That's reasonable—eh?"
"Very reasonable indeed. He's one with a good deal of sense to him. In
fact the man as have lived all his life with your mother-in-law must have
qualities out of the common," declared William. "But he haven't
neighboured with that amazing character all these years for nothing. How
much of his soul he calls his own, you may know better than me. 'Tis a case
of Aaron's rod swallowing the lesser, and he won't gainsay Mrs. Huxam in
anything, I'm afraid."
When he was gone, one thought of a comforting character remained
with the sick man. He had been much daunted with the tremendous moral
significance of the opinion of the world and its crushing censure. It had
weakened resolution and increased his self-condemnation. Now his friend
was able to assert that public emotion grew quieter against him; that even,
in some quarters, he had won an admission it might be reasonable for
husband and wife to come together again. This fact soothed Bullstone, for
like many, who do not court their fellow-creatures, he had been, none the
less, sensitive of their opinions and jealous of their approval. Herein,
therefore, appeared hope. He felt grateful to his old companion, who,
among so many words that to Jacob meant no comfort, was yet able to drop
this salutary consolation. He much desired to tell Auna, who had long been
the recipient of all his confidences and made older than her years by them.
CHAPTER VIII
JEREMY EVASIVE
After Margery knew her husband's desires, she was animated fitfully to
make an effort and return. But she lacked strength to do any such thing
single-handed. She had been losing vitality, yet so gradually, that none
about her appeared conscious of the fact. Even Auna saw her too often to
appreciate it. The girl came every week, but won no further opportunity to
see her mother alone. She opposed a sulky obstinacy to her grandmother
and Judith began to fear for her.
Then Margery saw her brother again and, with even less reticence than
on a former occasion, appealed to him. She had kept her original contract
and succeeded in winning her father. It was understood that Jeremy and
Jane would take over the post-office and the draper's shop, when the
Huxams went to their private house; and Jeremy, now accustomed to the
idea, argued that his sister had really not influenced the decision and that
she might not, therefore, fairly ask him to assist her present project. In fact
he much desired to be off the bargain, and but for Jane, would have evaded
it. She showed him, however, that this might not honourably be done and,
with very ill grace, Margery's brother listened to her purpose.
"I must go back when he does," explained Jacob's wife. "He's made a
good recovery, and can walk on crutches, and will soon be able to travel
with a stick. And the next thing will be the wedding, I suppose; and I ought
to be at my home for that. Because such a thing will break the ice and help
all round—at least so I feel and hope. I must go back, Jeremy. I'm called
stronger and stronger to it, and mother's awful ideas don't trouble me no
more. I've gone much farther than to forgive Jacob now. He's been very near
death and I ask myself what I'd have felt. But all that's my business. What I
beg from you, Jeremy, is just practical help—to meet me by night with your
trap, unbeknownst to any living thing but ourselves, and drive me back."
"I don't like it—I hate it," he answered. "It's not a religious action and
I'm very doubtful indeed if it's a wise one even from a worldly point of
view. The excitement will certainly be terrible bad for you, because you're
in no state at all to stand it."
"It may be kill or cure; but I'd far rather face it than go on like this—
seeing my bones come through my skin and my hair fail me. It'll soon be
now or never; but I do think, if I get back quietly and quickly, I'll build up
again and be some good to my family. I'm only sorry for mother."
Jeremy exploited the ethical objections.
"You see, Margery, it's quite as difficult for me as for you. As a matter
of fact you're putting a great charge on my conscience, because I've got to
go contrary to mother and behind her back—a thing I've never yet done—
and feeling as I do that she is right——"
"You've promised," interrupted Jane. "You promised to lend Margery a

hand if she helped you; and she did help you. And it's humbug to say you
never hid anything behind your mother's back, my dear man. What about it
when you married me?"
"I'm talking to Margery, not you," he replied, "and I was going to say
that somebody else might help her in the details much better than I could.
You see some think she's right, and such as them would do this with a much
better appetite than I shall. How if I was to drop a hint and get another man
to do it, Margery? It would be just the same to you and a good bit pleasanter
for me."
"There's nobody but you," she answered, "and it's properly unkind if
you're going back on your promise."
"He isn't," declared Jane with diplomacy. "He's a lot too fearless and a
lot too good a brother for that."
"I wouldn't say I promised; but of course if you feel I did——"

continued Jeremy. "However I've got rather a bright idea, and since you're
firm about this, and nobody will thank God better than your husband if you
do go back, then why not let him do it? That would be a natural seemly
arrangement since you both think alike. I'm perfectly willing to go to him
and tell him."
"No," said Margery. "That would upset everything I've planned. My

return must be a surprise for a thousand reasons. I want to go back as I
came out. In plain words, I've got to escape mother to go at all. Set like steel
as she is against any truck with Jacob, I have no choice but to deceive her.
I'm too weak to carry it off with a high hand, and she'd stop me if she
guessed I was thinking of it. Only I can't, of course, walk to Red House, and
so I must be drove; and you must drive me."
"If you're a man, you will, Jeremy," added Jane. "You promised."
"I bargain, then, that my part never comes out," said Jeremy, much
perturbed. "I consider this is something of a trap I'm in, and I don't think
much the better of you for it, Margery. And I believe you're courting a pack
of trouble, not to speak of Everlasting punishment if you go back to such a
man. But since you won't let me out, I'll do as you wish on the one
understanding, that my name's never whispered."
Neither Margery nor Jane, however, felt any sorrow for Jeremy.
"Thank you, then," said his sister. "It's only a question of waiting now
till my husband's well enough to go home. Then you can fix up a night, and
I'll husband my strength and come and meet you at Lydia Bridge, or
somewhere out of the way. We might do better to go round under Brent
Tor."
"We must leave the details for the present," said Jeremy, "and it will be
needful to wait till the nights are longer and darker."
Jane changed the subject.
"What about Avis and Bob?" she asked. "Jacob counts on their wedding
taking place from Red House—so Mr. Marydrew told me."
"It's going to be a difficult subject," answered Margery; "everything

must be difficult till we begin again; and mother won't do anything to make
it less difficult."
"Jacob naturally expects his daughter to be married from her home—

and why not?" asked Jane.
"Because it isn't her home," explained Jeremy. "You can't talk of Red
House being a home no longer, and mother's right there. Red House ceased
to be a home when Margery left it."
"But if I was back that would be altered," declared Margery. "It all
points to my going back. And mother will live to see it was right, if only for
our children's sakes."
Jeremy, however, would not allow this.
"Don't fox yourself to think so. Your children haven't any use for their
father and never will have. He's done for himself with them—all but Auna
—and when she's old enough to see the sense of it, no doubt she will."
"Jeremy's right," said Jane. "You mustn't think that, Margery. The boys
and Avis always did care a lot more for you than their father. They never hit
it, and you knew it, if Jacob did not."

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AACN Core Curriculum for Progressive

and Critical Care Nursing, 8e (May 19,

AACN Core Curriculum for High Acuity, Progressive and

AACN Essentials of Progressive Care Nursing, Third

AACN Essentials of Progressive Care Nursing, 5e (Sep

Synergy for Clinical Excellence: The AACN Model Patient

PeriAnesthesia Nursing Core Curriculum, 4e (April 9,

Core Curriculum for Forensic Nursing First Edition,

Medical-Surgical Nursing: Critical Thinking for

Critical care nursing certification. Johnson

Activate the complete learning experience that comes with each

You can now purchase Elsevier products on Evolve!

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

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

Executive Content Strategist: Lee Henderson

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

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

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

Patricia Radovich, PhD, CNS, FCCM

Angie Atwood, PhD, RN

Michele Beatty Bachmann, MSN, RN

Beverly L. Banks, BSN, MSN, RN

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

Collin Bowman-Woodall, MSN, RN

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

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

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

Christina Flint, MSN, MBA, RN

Matthew J. Fox, MSN, RN-BC

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

Charles R. Gold, BSN, RN, CCRN

Ami Grek, DNP, APRN, ACNP-BC

Christopher Guelbert, DNP, RN, CCRN, CNML

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

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

Jillian Hamel, MS, RN, ACNP-BC

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

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

Cheryl Holsworth, MSA, RN, CBN, CMSRN

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

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

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

Marianna LeCron Presley, MSN, RN, CCRN

KellyAnne Lee, MSN, MBA, RN, CCRN

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

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

Karen A. Matos, MSN, RN, CCRN

Paige McCraney, DNP, APRN

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

Katina M. Meyer, BSN, RN

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

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

Sarah Peacock, DNP, APRN, ACNP-BC

Deidra Pennington, MSN, RN

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

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

Janet Czermak Russell, DNP, RN, APN-BC

Peter D. Smith, BA, MSN, RN

Ashley N. Thompson, DNP, AGACNP-BC

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

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

Healthy Work Environment Standards (AACN, 2016)17

Ethical Clinical Practice24

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

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

Healthy Work Environment Standards (AACN, 2016)17

Ethical Clinical Practice24

Chapter 2 Psychosocial Aspects of Critical Care38

PART II ritical Care of Patients with Issues Affecting Specific Body

Specific Patient Health Problems 136

Chapter 4 Cardiovascular System 176

Specific Patient Health Problems 235

Chapter 5 Neurologic System 354

Specific Patient Health Problems 417

Chapter 6 Renal System490

Diagnostic Studies 507

Specific Patient Health Problems520

Chapter 7 Endocrine System564

Chapter 8 Hematologic and Immunologic Systems 593

Specific Patient Health Problems 604

Chapter 9 Gastrointestinal System 631

Specific Patient Health Problems 652

Chapter 11 Multisystem Trauma 706

Thoracic Trauma: Pulmonary and Cardiac

Chapter 14 Toxin Exposure 776

Care of the Bariatric Surgery Patient 806

Related Bariatric Care Issues807

Chapter 16 Older Adult Patients809

Age-Related Changes in Medication Action and Clinical Implications809

The Four Ms of Age-Friendly Health Care814

Chapter 17 High-Risk Obstetric Patients820

Specific Patient Health Problems823

Chapter 18 Patient Transport836

Indications for Transport837

Modes of Interfacility Transport838

Risks and Stresses of Transport839

Overriding Priorities in Patient Transport841

Preparation for Transport841

Patient Care During Transport844

Legal and Ethical Issues Related to Transport845

Specific Patient Health Problems855

Specific Clinical Problems Related to Pain Therapy885

Specific Patient Health Problems886

Chapter 21 Palliative and End-of-Life Care888

Chapter 22 Perioperative Care898

Specific Patient Health Problems917