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Nursing Care Plans

& Documentation
Nursing Diagnoses and Collaborative Problems
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Nursing Care Plans

& Documentation
Nursing Diagnoses and Collaborative Problems

Lynda Juall Carpenito-Moyet, R.N., M.S.N., C.R.N.P.

Family Nurse Practitioner
ChesPenn Health Services
Chester, Pennsylvania
Nursing Consultant
Mullica Hill, New Jersey

EDITION5
11075-00_FMrev.qxd 8/7/08 10:28 AM Page iv

Senior Acquisitions Editor: Jean Rodenberger

Managing Editor: Michelle Clarke
Production Editor: Mary Kinsella
Director of Nursing Production: Helen Ewan
Senior Managing Editor / Production: Erika Kors
Design Coordinator: Joan Wendt
Manufacturing Coordinator: Karin Duffield
Indexer: Coughlin Indexing Services, Inc.
Production Services / Compositor: Circle Graphics

5th Edition

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Copyright © 2004, 1999 by Lippincott Williams and Wilkins. Copyright © 1995, 1991 by J. B. Lippincott
Company.
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or trans-
mitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or
utilized by any information storage and retrieval system without written permission from the copyright
owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this
book prepared by individuals as part of their official duties as U.S. government employees are not covered
by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins
at 530 Walnut Street, Philadelphia, PA 19106, via email at [email protected], or via our website at
lww.com (products and services).

9 8 7 6 5 4 3 2 1

Printed in China

Library of Congress Cataloging-in-Publication Data

Carpenito-Moyet, Lynda Juall.

Nursing care plans & documentation : nursing diagnoses and collaborative problems /
Lynda Juall Carpenito-Moyet.—5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-7064-4 (alk. paper)
1. Nursing care plans. 2. Nursing assessment. 3. Nursing diagnosis. I. Title. II. Title: Nursing
care plans and documentation.
[DNLM: 1. Patient Care Planning. 2. Nursing Process. 3. Nursing Records. WY 100
C294n 2008]
RT49.C38 2008
610.73—dc22
2008016029

Care has been taken to confirm the accuracy of the information presented and to describe generally
accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions
or for any consequences from application of the information in this book and make no warranty, expressed
or implied, with respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional responsibility of the practi-
tioner; the clinical treatments described and recommended may not be considered absolute and universal
recommendations.

The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with the current recommendations and practice at the time of publica-
tion. However, in view of ongoing research, changes in government regulations, and the constant flow of
information relating to drug therapy and drug reactions, the reader is urged to check the package insert for
each drug for any change in indications and dosage and for added warnings and precautions. This is partic-
ularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health care provider to
ascertain the FDA status of each drug or device planned for use in his or her clinical practice.

LWW.com
11075-00_FMrev.qxd 8/7/08 10:28 AM Page v

To My Mother: Elizabeth Julia Juall

Every year brings me a new appreciation and admiration for this woman
In her 80s (close to 90) there is not much she does not do
She has role-modeled unconditional love, respect for all, forgiveness, and independence
She is determined she can, and she does!
She is one generation of my family’s Hungarian Woman Warriors, and I proudly walk in
their footprints, carry their swords to battle injustice, and cherish deeply our loved ones.

Love your daughter

Lynda
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Current Contributors

John Dugan, R.N., B.S.N. Tracy Schreiner, R.N., M.S.N., M.B.A.

Manager, Intensive Care Unit President, Schreiner Consulting
Carondelet Health Network Adjunct Faculty
St. Joseph’s Hospital Grand Canyon University
Tucson, Arizona Phoenix, Arizona
(Cardiovascular and Peripheral Vascular Disorders) Chamberlain College of Nursing
Chamberlin, Ohio
Gloria J. Gdovin, R.N., M.S.N., [Respiratory Disorders, Osteoporosis, Osteomyelitis,
C.C.R.N. (Diagnostic and Therapeutic Procedures: Anticoagulant
Clinical Nurse Educator, Critical Care Therapy, Casts, Chemotherapy, Corticosteroid
Carondelet Health Network Therapy, Enteral Nutrition, Long-Term Venous
St. Joseph’s Hospital Access, Pacemaker Insertion, Radiation Therapy,
Tucson, Arizona Total Parenteral Nutrition)]
[Stroke, Multiple Sclerosis, Neurogenic Bladder,
Fractures, Osteomyelitis, Neoplastic Disorders,
Pressure Ulcers, Immobility, HIV-Aids, Systemic
Previous Contributors
Lupus, Glaucoma, (Surgical Procedures: Abdominal Caroline M. Alterman, M.S.N., C.N.S.
Aortic Aneurysm Repair, Amputation, Arterial Bypass, Director, Spinal Cord Injury Program, Lakeshore
Breast Surgery, Carotid Endarectomy, Coronary Rehabilitation Hospital, Birmingham, Alabama
Bypass Graft, Radical Prostatectomy, Thoracic (Spinal Cord Injury, 2nd ed.)
Surgery, Total Joint Replacement, Urostomy)]
Elizabeth Brady-Avis, R.N., M.S.N.,
Susan Laureen Jones, R.N., B.S.N., C.C.R.N.
C.C.R.N. Clinical Nurse Specialist, Thomas Jefferson
Clinical Specialist, Inpatient Neuroscience University Hospital, Philadelphia,
Carondelet Health Network Pennsylvania
St. Joseph’s Hospital
Tucson, Arizona (Mechanical Ventilation, Asthma)

[Cancer End-Stage, Alcohol Withdrawal, Thermal Sharon Buckingham, B.S.N.

Injuries, Spinal Cord Injury, Seizures, Parkinson Staff Nurse, ICU, Huron Valley Hospital,
Disease, Myasthenia Gravis, Guillain-Barré, Milford, Michigan
Inflammatory Joint Disease, Renal and Urinary
Disorders, Peritoneal Dialysis, Hemodialysis, Sexual (Hypertension, Cirrhosis, 2nd ed.)
Assault, (Surgical Procedures: Generic Surgery,
Nephrectomy, Enucleation, Cranial Surgery, Cataract Gerald A. Burns, M.S.N.
Extraction, Laryngectomy, Ileostomy, Fractured Hip Clinical Nurse Specialist/Case Manager, Harper
and Femur, Neck Dissection, Laminectomy, Hospital, Detroit, Michigan
Hysterectomy, Colostomy)] (Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome)

vii
11075-00_FMrev.qxd 8/7/08 10:28 AM Page viii

viii Current Contributors

Ann Delengowski, R.N., M.S.N. Amy Ottariano, R.N., M.S.N.

Oncology Clinical Nurse Specialist, Thomas Clinical Nurse Specialist, Intermediate Cardiac
Jefferson University Hospital, Philadelphia, Care Unit, Thomas Jefferson University
Pennsylvania Hospital, Philadelphia, Pennsylvania
(Leukemia, Sickle Cell Anemia, 2nd ed.) (Thoracic Surgery, 2nd ed.)

Mary Ann Ducharme, R.N., M.S.N., Rhonda R. Panfilli, R.N., M.S.N.

C.C.R.N. Coordinator, Case Management, Grace Hospital,
Case Manager/Clinical Nurse Specialist, Harper Detroit Medical Center, Detroit, Michigan
Hospital, Detroit, Michigan (Obesity)
(Hemodynamic Monitoring, Peritoneal Dialysis)
Gayle Vandendool Parker, R.N., B.S.N.
Rita Dundon, R.N., M.S.N., C.S., O.C.N. Nursing Practice Coordinator, London
Clinical Nurse Specialist, Henry Ford Hospital, Psychiatric Hospital, London, Ontario, Canada
Detroit, Michigan (Alcohol Withdrawal)
[Cancer (Initial Diagnosis), Chemotherapy, End-Stage
Cancer, Long-Term Venous Access Devices] Joy Ross, R.N.
London Psychiatric Hospital, London,
Doris R. Fleming, M.S.N., R.N., Ontario, Canada
C.S., C.D.E. (Sexual Assault)
Clinical Nurse Specialist, Harper Hospital,
Detroit, Michigan Rose B. Shaffer, R.N., M.S.N., C.C.R.N.
(Diabetes Mellitus) Clinical Nurse Specialist, Intermediate Cardiac
Care Unit, Thomas Jefferson University
Andrea Sampson Haggood, Hospital, Philadelphia, Pennsylvania
M.S.N., R.N. (Cardiac Catheterization, Pacemaker Insertion)
Clinical Nurse Specialist/Case Manager,
Oncology and Otorhinolaryngology, Harper Ellen Stefanosky, R.N., M.S.N.
Hospital, Detroit, Michigan Transplant Coordinator, Thomas Jefferson
University Hospital, Philadelphia,
(Tracheostomy, Neck Dissection, Laryngectomy, 2nd ed.)
Pennsylvania
Evelyn Howard, R.N., C.N.N. (Renal Transplant, 2nd ed.)
Director, Renal Dialysis, St. Vincent Infirmary
Medical Center, Little Rock, Arkansas Patricia A. Vaccaro, R.N., M.S.N.
Clinical Nurse Facilitator, Burn Center, Lehigh
(Acute Renal Failure, Chronic Renal Failure, 2nd ed.)
Valley Hospital, Allentown, Pennsylvania
Debra J. Lynn-McHale, R.N., M.S.N., (Thermal Injuries, 2nd ed.)
C.S., C.C.R.N.
Clinical Nurse Specialist, Surgical Cardiac Care Donna J. Zazworsky, R.N., M.S.
Unit, Thomas Jefferson University Hospital, Professional Nurse Case Manager, Carondelet St.
Philadelphia, Pennsylvania Mary’s Hospital, Tucson, Arizona

(Coronary Artery Bypass Graft, Percutaneous (Multiple Sclerosis)

Transluminal Coronary Angioplasty)

JoAnn Maklebust, M.S.N., R.N., C.S.

Clinical Nurse Specialist/Wound Care, Case
Manager/General and Reconstructive Surgery,
Harper Hospital, Detroit, Michigan
(Colostomy, Ileostomy, Urostomy, Pressure Ulcers,
Inflammatory Bowel Disease, Neurogenic Bladder)
11075-00_FMrev.qxd 8/7/08 10:28 AM Page ix

Preface

Nursing is primarily assisting individuals, sick or well, in activities that contribute to health or its recovery, or to
a peaceful death, and that they perform unaided when they have the necessary strength, will, or knowledge.
Nursing also helps individuals carry out prescribed therapy and to be independent of assistance as soon as possible
(Henderson, 1960).
Historically, nurses have represented the core of the health care delivery system (including acute,
long-term, and community agencies), but their image continues to be one of individuals whose actions
are dependent on physician supervision. Unfortunately, what Donna Diers wrote over 15 years ago is
still relevant today: “Nursing is exceedingly complicated work since it involves technical skill, a great
deal of formal knowledge, communication ability, use of self, timing, emotional investment, and any
number of other qualities. What it also involves—and what is hidden from the public—is the complex
process of thinking that leads from the knowledge to the skill, from the perception to the action, from
the decision to the touch, from the observation to the diagnosis. Yet it is this process of nursing care, which is
at the center of nursing’s work, that is so little described . . .” (Diers, 1981, p. 1, emphasis supplied).
Physicians regularly and openly explain the measures they plan to the public, especially to clients
and their families. Nurses, however, often fail to consistently explain their plan of care to clients and
family. This book provides both a framework for nurses to provide responsible nursing care and guide-
lines for them to document and communicate that care. These care plans should not be hand-written.
They must be reference documents for practicing nurses. Write or free text the different care the client
needs in addition to the standard.
The focus of Nursing Care Plans and Documentation is independent nursing care—the manage-
ment of client situations that the nurse can treat legally and independently. It will assist students in
transferring their theoretical knowledge to clinical practice; it can help experienced nurses provide
care in a variety of unfamiliar clinical situations. This book also incorporates the findings of a valida-
tion study, a description of which (method, subjects, instrument findings) is presented in the section
titled Validation Project, following the Preface. These findings should be very useful for practicing
nurses, students of nursing, and departments of nursing.
The Bifocal Clinical Practice Model underpins this book and serves to organize the nursing care
plans in Unit II. Chapter 1 describes and discusses the Bifocal Clinical Practice Model, which differen-
tiates nursing diagnoses from other problems that nurses treat. In this chapter, nursing diagnoses and
collaborative problems are explained and differentiated. The relationship of the type of diagnosis to
outcome criteria and nursing interventions is also emphasized.
Efficient and appropriate documentation of nursing care is outlined in Chapter 2. Legal issues,
standards, and regulatory agencies and their effect on nursing documentation are discussed. The chapter
explains a documentation system from admission to discharge. Sample forms are used to emphasize
efficient, professional charting. This chapter also includes a discussion of priority diagnoses and case
management. The elements of critical pathways are explained with examples. Directions on how to
create critical pathways using the care plans in Unit II are discussed and illustrated.
Chapter 3 gives an overview of the 11 steps in care planning and takes the reader through each
phase of this process.
Chapter 4 explores the issues and human responses associated with illness and hospitalization, and
describes the coping strategies of the client and family. A discussion of Bandura’s self-efficacy theory and
its application to management of therapeutic regimens is also presented.
Chapter 5 focuses on the surgical experience and related nursing care to discuss the human
response to the experience. Preoperative assessment and preparation are described for preadmitted
and same-day-admission surgical clients. The nursing responsibilities in the postanesthesia recovery
room are described, and the related documentation forms are included. This chapter also outlines the
integration of the nursing process in caring for same-day surgery clients; again, the corresponding
forms that will help the nurse to do this are included.
New to this edition is Chapter 6. This chapter focuses on Moral Distress in nurses. This new
NANDA nursing diagnosis has the nurse as the focus, not the client. The clinical reality of Moral
ix
11075-00_FMrev.qxd 8/7/08 10:28 AM Page x

x Preface

Distress in nursing will be explored, and strategies for preventing and reducing Moral Distress will be
presented. Self-Assessment of Health Behaviors will help the nurse with a self-evaluation of his or her
life style. End-of-Life Decisions will be explored and strategies for promoting these decisions in one’s
personal life and with clients will be discussed. A reproducible Living Will document is available for
distribution with instructions on how to use it.
Unit II presents care plans that represent a compilation of the complex work of nursing in caring for
individuals (and their families) experiencing medical disorders or surgical interventions or undergoing
diagnostic or therapeutic procedures. It uses the nursing process to present the type of nursing care that
is expected to be necessary for clients experiencing similar situations. The plans provide the nurse with a
framework for providing initial, or essential, care. This is the nursing care known to be provided when a
certain clinical situation is present—for example, preoperative teaching for clients awaiting surgery or
the management of fatigue in individuals with arthritis. As the nurse intervenes and continues to assess,
additional diagnoses, goals, and interventions can be added to the initial plan. Even though the type of
care that is warranted for clients in certain clinical situations is predictable, the nurse must still assess the
individual for additional responses. The fifth edition features extensive revisions or additions to the
goals/outcome criteria in each care plan and, when possible, research findings or the work of expert
clinicians were incorporated.
The intent of this book is to assist the nurse to identify the responsible care that nurses are account-
able to provide. The incorporation of recent research findings further enhances the applicability of the
care plans. By using the Bifocal Clinical Practice Model, the book clearly defines the scope of indepen-
dent practice. The author invites comments and suggestions from readers. Correspondence can be
directed to the publisher or to the author’s address.

REFERENCES
Diers, D. (1981). Why write? Why publish? Image, 13, 991–997
Henderson, V. & Nite, G. (1960). Principles and practice of nursing (5th ed.). New York: Macmillan, p. 14.
11075-00_FMrev.qxd 8/7/08 10:28 AM Page xi

Validation Project

Background
In 1984, this author published diagnostic clusters under medical and surgical conditions (Carpenito,
1984). These diagnostic clusters represented nursing diagnoses and collaborative problems described in
the literature for a medical or surgical population. After the initial diagnostic clusters were created, they
were reviewed by clinicians who practiced with specific corresponding populations.
Since 1984, numerous other authors (Holloway, 1988; Doenges, 1991; Sparks, 1993; Ulrich,
1994) have generated similar groupings. To date none of the clusters have been studied to determine
their frequency of occurrence. In other words, are some diagnoses in the diagnostic cluster treated
more frequently than others?

Reasons for Study

In the last 10 years, the health care delivery system has experienced numerous changes. Specifically, clients
are in the acute care setting for shorter periods. These client populations all share a high acuity. This acuity
is represented with multiple nursing diagnoses and collaborative problems. However, do all these diagnoses
have the same priority? Which diagnoses necessitate nursing interventions during the length of stay?
Care planning books report a varied number of diagnoses to treat under a specific condition. For
example, in reviewing a care plan for a client with a myocardial infarction, this author found the follow-
ing number of diagnoses reported: Ulrich, 16; Carpenito, 11; Doenges, 7; Holloway, 4. When students
review these references, how helpful are lists ranging from 4 to 16 diagnoses? How many diagnoses can
nurses be accountable for during a client’s length of stay?
The identification of nursing diagnoses and collaborative problems that nurses treat more frequently
than others in certain populations can be very useful data to:
• Assist nurses with decision making
• Determine the cost of nursing services for population sets
• Plan for resources needed
• Describe the specific responsibilities of nursing
Novice nurses and students can use these data to anticipate the initial care needed. They can
benefit from data reported by nurses experienced in caring for clients in specific populations.
These data should not eliminate an assessment of an individual client to evaluate if additional
nursing diagnoses or collaborative problems are present and establish priority for treatment during the
hospital stay. This individual assessment will also provide information to delete or supplement the care
plan found in this book. The researched data will provide a beginning focus for care.
By identifying frequently treated nursing diagnoses and collaborative problems in client populations,
institutions can determine nursing costs based on nursing care provided. Nurse administrators and managers
can plan for effective use of staff and resources. Knowledge of types of nursing diagnoses needing nursing
interventions will also assist with matching the level of preparation of nurses with appropriate diagnoses.
To date, the nursing care of clients with medical conditions or postsurgical procedures has centered
on the physician-prescribed orders. The data from this study would assist departments of nursing to
emphasize the primary reason why clients stay in the acute care setting—for treatment of nursing diagnoses
and collaborative problems. The purpose of this study is to identify which nursing diagnoses and collabora-
tive problems are most frequently treated when a person is hospitalized with a specific condition.

Method
Settings and Subjects
The findings presented are based on data collected from August 1993 to March 1994. The research
population consisted of registered nurses with over 2 years’ experience in health care agencies in the
United States and Canada. A convenience sample of 18 institutions represented five U.S. geographical

xi
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xii Validation Project

regions (Northeast, Southeast, North-Midwest, Northwest, Southwest) and Ontario province in

Canada. The display lists the participating institutions. The target number of R.N. responses was
10 per condition from each institution. The accompanying table illustrates the demographics of the
subjects.

Instrument
A graphic rating scale was developed and pilot-tested to measure self-reported frequencies of interven-
tions provided to clients with a specific condition. Each collaborative problem listed under the condition
was accompanied by the question:
When you care for clients with this condition, how often do you monitor for this problem?
Each nursing diagnosis listed under the condition was accompanied by the question:
When you care for clients with this condition, how often do you provide interventions for this nursing
diagnosis?
The respondent was asked to make an X on a frequency scale of 0% to 100%. Scoring was tabu-
lated by summing the scores for each question and calculating the median.

PARTICIPATING INSTITUTIONS

Allen Memorial Hospital Presbyterian Hospital University of Minnesota Hospital

1825 Logan Avenue 200 Hawthorne Lane 420 Delaware Street, S.E.
Waterloo, Iowa 50703 Charlotte, NC 28233-3549 Minneapolis, MN 55455
Carondelet St. Joseph’s Hospital St. Francis Medical Center University of New Mexico Hospital
350 N. Wilmont Road 211 St. Francis Drive 2211 Lomas Blvd., N.E.
Tucson, AZ 85711-2678 Cape Girardeau, MO 63701 Albuquerque, NM 87131
The Evanston Hospital St. Joseph Hospital Victoria Hospital
Burch Building 601 N. 30th Street 800 Commissioners Road, East
2650 Ridge Avenue Omaha, NE 68131 London, Canada N6A 4G5
Evanston, IL 60201 St. Peter Community Hospital Wills Eye Hospital
Huron Valley Hospital 2475 Broadway 900 Walnut Street
1601 East Commerce Road Helena, MT 39601 Philadelphia, PA 19107
Milford, MI 48382-9900 San Bernardino County Medical Wilmer Ophthalmological Institute
Lehigh Valley Hospital Center Johns Hopkins Hospital
Cedar Crest & I-78 780 E. Gilbert Street Baltimore, MD 21287-9054
Allentown, PA 18105-1556 San Bernardino, CA 92415-0935 Winthrop-University Hospital
Memorial Medical Center of Sioux Valley Hospital 259 First Street
Jacksonville 1100 South Euclid Avenue Mineola, NY 11501
3625 University Blvd., South Sioux Falls, SD 57117-5039
Jacksonville, FL 32216

Data Collection
Prior to data collection, the researcher addressed the requirements for research in the institution. These
requirements varied from a review by the nursing department’s research committee to a review by the
institutional review board (IRB).
After the approval process was completed, each department of nursing was sent a list of the 72
conditions to be studied and asked to select only those conditions that were regularly treated in their
institution. Only those questionnaires were sent to the respective institutions. Study institutions received
a packet for those selected conditions containing 10 questionnaires for each condition. Completed ques-
tionnaires were returned by the nurse respondent to the envelope and the envelope sealed by the desig-
nated distributor. Nurse respondents were given the option of putting their questionnaire in a sealed
envelope prior to placing it in the larger envelope.
Since two of the study institutions did not treat ophthalmic conditions, questionnaires related to
these conditions were sent to two institutions specializing in these conditions.
11075-00_FMrev.qxd 8/7/08 10:28 AM Page xiii

Validation Project xiii

Findings
Of the 19 institutions that agreed to participate, 18 (including the two ophthalmic institutions) returned
the questionnaires. The target return was 160 questionnaires for each condition. The range of return was
29% to 70%, with the average rate of return 52.5%.
Each condition has a set of nursing diagnoses and collaborative problems with its own frequency
score. The diagnoses were grouped into three ranges of frequency: 75% to 100%—frequent; 50% to
74%—often; <50%—infrequent. Each of the 72 conditions included in the study and in this book has
the nursing diagnoses and collaborative problems grouped according to the study findings.

Future Work
This study represents the initial step in the validation of the nursing care predicted to be needed when a
client is hospitalized for a medical or surgical condition. It is important to validate which nursing diag-
noses and collaborative problems necessitate nursing interventions. Future work will include the identifi-
cation of nursing interventions that have priority in treating a diagnosis, clarification of outcomes
realistic for the length of stay, and evaluation and review by national groups of nurses.

DEMOGRAPHICS OF RESPONDENTS
Questionnaires
Sent 9,920
Returned 5,299
% returned 53.4%
Average Age 39
Average Years in Nursing 15

Level of Nursing Preparation

Diploma 22.7%
AD 25.7%
BSN 36.5%
MSN 12.4%
PhD 1.5%
No indication 1.2%

REFERENCES
Carpenito, L. J. (1984). Handbook of nursing diagnosis. Philadelphia: J. B. Lippincott.
Carpenito, L. J. (1991). Nursing care plans and documentation. Philadelphia: J. B. Lippincott.
Doenges, M., & Moorhouse, M. (1991). Nurse’s pocket guide: Nursing diagnoses with interventions. Philadelphia:
F. A. Davis.
Holloway, N. M. (1988). Medical surgical care plans. Springhouse, PA: Springhouse.
Sparks, S. M., & Taylor, C. M. (1993). Nursing diagnoses reference manual. Springhouse, PA: Springhouse.
Ulrich, S., Canale, S., & Wendell, S. (1994). Medical-surgical nursing: Care planning guide. Philadelphia:
W. B. Saunders.
11075-00_FMrev.qxd 8/7/08 10:28 AM Page xiv

xiv Validation Project

Acknowledgments
The Validation Project could not have been completed without the support of the following nurses who
coordinated the data collection in their institutions:
Tammy Spier, R.N., M.S.N. Pauline Elliott, R.N., B.S.N.
Department of Nursing Services St. Francis Medical Center
Department of Staff Development Cape Girardeau, Missouri
Allen Memorial Hospital Dena Belfiore, R.N., Ph.D.
Waterloo, Iowa Dianne Hayko, M.S.R.N., C.N.S.
Donna Dickinson, R.N., M.S. St. Joseph Hospital
Carol Mangold, R.N., M.S.N. Omaha, Nebraska
Carondelet St. Joseph’s Hospital Jennie Nemec, R.N., M.S.N.
Tucson, Arizona St. Peter Community Hospital
Kathy Killman, R.N., M.S.N. Helena, Montana
Liz Nelson, R.N., M.S.N. Eleanor Borkowski, R.N.
The Evanston Hospital Tina Buchanan, R.N.
Evanston, Illinois Jill Posadas, R.N.
Margaret Price, R.N., M.S.N. Deanna Stover, R.N.
Lynn Bobel Turbin, R.N., M.S.N. Margie Bracken, R.N.
Nancy DiJanni, R.N., M.S.N. Barbara Upton, R.N.
Huron Valley Hospital Kathleen Powers, R.N.
Milford, Michigan Jeanie Goodwin, R.N.
Pat Vaccaro, R.N., B.S.N., C.C.R.N. San Bernardino County Medical Center
Deborah Stroh, R.N. San Bernardino, California
Mary Jean Potylycki, R.N. Kathy Karpiuk, R.N., M.N.E.
Carolyn Peters, R.N. Monica Mauer, R.N.
Sue DeSanto, R.N. Susan Fey, R.N.
Christine Niznik, R.N. Joan Reisdorfer, R.N.
Carol Saxman, R.N. Cheryl Wilson, Health Unit Coordinator
Kelly Brown, R.N. Gail Sundet, R.N.
Judy Bailey, R.N. Pat Halverson, R.N.
Nancy Root, R.N. Ellie Baker, R.N.
Cheryl Bitting, R.N. Jackie Kisecker, R.N.
Carol Sorrentino, R.N. Cheri Dore-Paulson, R.N.
Lehigh Valley Hospital Kay Gartner, R.N.
Allentown, Pennsylvania Vicki Tigner, R.N.
Loretta Baldwin, R.N., B.S.N. Jan Burnette, R.N.
Karin Prussak, R.N., M.S.N., C.C.R.N. Maggie Scherff, R.N.
Bess Cullen, R.N. Sioux Valley Hospital
Debra Goetz, R.N., M.S.N. Sioux Falls, South Dakota
Susan Goucher, R.N. Keith Hampton, R.N., M.S.N.
Sandra Brackett, R.N., B.S.N. University of Minnesota Hospital
Barbara Johnston, R.N., C.C.R.N. Minneapolis, Minnesota
Lisa Lauderdale, R.N. Eva Adler, R.N., M.S.N.
Randy Shoemaker, R.N., C.C.R.N. Jean Giddens, R.N., M.S.N., C.S.
Memorial Medical Center of Jacksonville Dawn Roseberry, R.N., B.S.N.
Jacksonville, Florida University of New Mexico Hospital
Karen Stiefel, R.N., Ph.D. Albuquerque, New Mexico
Jerre Jones, R.N., M.S.N., C.S.
Lise Heidenreich, R.N., M.S.N., F.N.P., C.S.
Christiana Redwood-Sawyerr, R.N., M.S.N.
Presbyterian Hospital
Charlotte, North Carolina
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Validation Project xv

Fran Tolley, R.N., B.S.N. My gratitude also extends to each of the nurses
Vicky Navarro, R.N., M.A.S. who gave their time to complete the question-
Wilmer Ophthalmological Institute naires.
Johns Hopkins Hospital A sincere thank you to Dr. Ginny
Baltimore, Maryland Arcangelo, Director of the Family Nurse
Heather Boyd-Monk, R.N., M.S.N. Practitioner Program at Thomas Jefferson
Wills Eye Hospital University in Philadelphia, for her work as the
Philadelphia, Pennsylvania methodology consultant to the project.
A study of this magnitude required over
Joan Crosley, R.N., Ph.D. 9000 questionnaires to be produced, duplicated,
Winthrop-University Hospital and distributed. Over 100,000 data entries were
Mineola, New York made, yielding the findings found throughout this
Carol Wong, R.N., M.Sc.N. edition.
Cheryl Simpson, R.N.
Victoria Hospital
London, Canada
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Contents

UNIT I
Introduction to Care Planning 1
Chapter 1 The Bifocal Clinical Practice Model 3
Chapter 2 Documentation of Nursing Care 9
Chapter 3 11 Steps to Care Planning 27
Chapter 4 The Ill Adult: Issues and Responses 32
Chapter 5 Response to the Surgical Experience 38
Chapter 6 Reducing Moral Distress in Nurses 50

UNIT II
Clinical Nursing Care Plans 55

Section 1 ◗ MEDICAL CONDITIONS 61

Generic Medical Care Plan for the Hospitalized Multiple Sclerosis 258
Adult Client 62 Myasthenia Gravis 269
Cardiovascular and Peripheral Vascular Neurogenic Bladder 275
Disorders 83 Parkinson Disease 286
Heart Failure 83 Seizure Disorders 292
Deep Venous Thrombosis 87 Spinal Cord Injury 298
Hypertension 93 Hematologic Disorders 318
Acute Coronary Syndrome 99 Sickle Cell Disease 318
Peripheral Arterial Disease Integumentary Disorders 326
(Atherosclerosis) 110 Pressure Ulcers 326
Respiratory Disorders 118 Thermal Injuries 334
Asthma 118 Musculoskeletal and Connective
Chronic Obstructive Pulmonary Tissue Disorders 354
Disease 125 Fractures 354
Pneumonia 137 Inflammatory Joint Disease (Rheumatoid
Metabolic and Endocrine Disorders 145 Arthritis, Infectious Arthritis, or Septic
Cirrhosis 145 Arthritis) 360
Diabetes Mellitus 152 Osteomyelitis 375
Hepatitis (Viral) 163 Osteoporosis 379
Hypothyroidism 168 Infectious and Immunodeficient Disorders 385
Obesity 174 Human Immunodeficiency Virus/Acquired
Pancreatitis 180 Immunodeficiency Syndrome 385
Gastrointestinal Disorders 190 Systemic Lupus Erythematosus 400
Gastroenterocolitis/Enterocolitis 190 Neoplastic Disorders 407
Inflammatory Bowel Disease 194 Cancer: Initial Diagnosis 407
Peptic Ulcer Disease 206 Cancer: End-Stage 417
Renal and Urinary Tract Disorders 212 Leukemia 433
Acute Kidney Failure 212 Clinical Situations 441
Chronic Kidney Disease 219 Alcohol Withdrawal Syndrome 441
Neurologic Disorders 236 Immobility or Unconsciousness 450
Cerebrovascular Accident (Stroke) 236 Sexual Assault 457
Guillain-Barré Syndrome 251
xvii
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xviii Contents

Section 2 ◗ SURGICAL PROCEDURES 463

Generic Care Plan for the Surgical Client 464 Fractured Hip and Femur 572
Abdominal Aortic Aneurysm Resection 480 Hysterectomy 584
Amputation 485 Ileostomy 590
Arterial Bypass Grafting in the Laminectomy 606
Lower Extremity 497 Laryngectomy 612
Breast Surgery (Lumpectomy, Mastectomy) 503 Neck Dissection 614
Carotid Endarterectomy 511 Nephrectomy 624
Cataract Extraction 517 Radical Prostatectomy 629
Colostomy 525 Thoracic Pulmonary Surgery 636
Coronary Artery Bypass Grafting 540 Total Joint Replacement
Cranial Surgery 554 (Hip, Knee, Shoulder) 647
Enucleation 565 Urostomy 655

Section 3 ◗ DIAGNOSTIC AND THERAPEUTIC PROCEDURES 667

Anticoagulant Therapy 668 References/Bibliography 764
Casts 672 Appendix 778
Chemotherapy 678
Corticosteroid Therapy 691
Clinical Situations Index 787
Enteral Nutrition 699 Nursing Diagnoses Index 789
Hemodialysis 707 Collaborative Problems Index 796
Long-Term Venous Access Devices 713 General Index 802
Mechanical Ventilation 719
Pacemaker Insertion (Permanent) 726
Peritoneal Dialysis 736
Radiation Therapy 746
Total Parenteral Nutrition 756
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UNIT

I
Introduction to
Care Planning
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1 THE BIFOCAL CLINICAL

PRACTICE MODEL

The classification activities of the North American Nursing Diagnosis Association International
(NANDA-I) have been instrumental in defining nursing’s unique body of knowledge. This unified system
of terminology
• Provides consistent language for oral, written, and electronic communication
• Stimulates nurses to examine new knowledge
• Establishes a system for automation and reimbursement
• Provides an educational framework
• Allows efficient information retrieval for research and quality assurance
• Provides a consistent structure for literature presentation of nursing knowledge
• Clarifies nursing as an art and a science for its members and society
• Establishes standards to which nurses are held accountable
The inside cover of this text provides a list of nursing diagnoses grouped under conditions that necessitate
nursing care.
Clearly, nursing diagnosis has influenced the nursing profession positively. Integration of nursing diag-
nosis into nursing practice, however, has proved problematic. Although references to nursing diagnosis in the
literature have increased 100-fold since the first meeting in 1973 of the National Group for the Classification
of Nursing Diagnoses (which later became NANDA-I), nurses have not seen efficient and representative appli-
cations. For example, nurses have been directed to use nursing diagnoses exclusively to describe their clinical
focus. Nevertheless, nurses who strongly support nursing diagnosis often become frustrated when they try to
attach a nursing diagnosis label to every facet of nursing practice. Some of the dilemmas that result from the
attempt to label as nursing diagnoses all situations in which nurses intervene are as follows:
1. Using nursing diagnoses without validation. When the nursing diagnoses are the only labels or diagnostic
statements the nurse can use, the nurse is encouraged to “change the data to fit the label.” For exam-
ple, using the Imbalanced Nutrition category for all clients who are given nothing-by-mouth status.
Risk for Injury also frequently serves as a “wastebasket” diagnosis because all potentially injurious situ-
ations (e.g., bleeding) can be captured within a Risk for Injury diagnosis.
2. Renaming medical diagnoses. Clinical nurses know that an important component of their practice is
monitoring for the onset and status of physiologic complications and initiating both nurse-prescribed
and physician-prescribed interventions. Morbidity and mortality are reduced and prevented because
of nursing’s expert management.
If nursing diagnoses are to describe all situations in which nurses intervene, then clearly a vast
number must be developed to describe the situations identified in the International Code of Diseases
(ICD-10). Table 1.1 represents examples of misuse of nursing diagnoses and the renaming of medical
diagnoses. Examination of the substitution of nursing diagnosis terminology for medical diagnoses or
pathophysiology in Table 1.1 gives rise to several questions:
• Should nursing diagnoses describe all situations in which nurses intervene?
• If a situation is not called a nursing diagnosis, is it then less important or scientific?
• How will it serve the profession to rename medical diagnoses as nursing diagnoses?
• Will using the examples in Table 1.1 improve communication and clarify nursing?
3. Omitting problem situations in documentation. If a documentation system requires the use of nursing
diagnosis exclusively, and if the nurse does not choose to “change the data to fit a category” or “to
rename medical diagnoses,” then the nurse has no terminology to describe a critical component of
nursing practice. Failure to describe these situations can seriously jeopardize nursing’s effort to justify
and affirm the need for professional nurses in all health care settings (Carpenito, 1983).

3
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4 Introduction to Care Planning

TABLE 1.1 Diagnostic Errors: Renaming Medical Diagnoses With

Nursing Diagnosis Terminology
Medical Diagnosis Nursing Diagnosis
Myocardial Infarction Decreased Cardiac Output

Shock Decreased Cardiac Output

Adult Respiratory Distress Impaired Gas Exchange

Chronic Obstructive Lung Disease Impaired Gas Exchange

Asthma Impaired Gas Exchange

Alzheimer’s Disease Impaired Cerebral Tissue Perfusion

Increased Intracranial Pressure Impaired Cerebral Tissue Perfusion

Retinal Detachment Disturbed Sensory Perception: Visual

Thermal Burns Impaired Tissue Integrity

Incisions, Lacerations Impaired Skin Integrity

Hemorrhage Deficient Fluid Volume

Congestive Heart Failure Excess Fluid Volume

Bifocal Clinical Practice Model

Nursing’s theoretical knowledge derives from the natural, physical, and behavioral sciences, as well as the
humanities and nursing research. Nurses can use various theories in practice, including family systems, loss,
growth and development, crisis intervention, and general systems theories.
The difference between nursing and the other health care disciplines is nursing’s depth and breadth
of focus. Certainly the nutritionist has more expertise in the field of nutrition and the pharmacist in the
field of therapeutic pharmacology than any nurse. Every nurse, however, brings a knowledge of nutrition
and pharmacology to client interactions. The depth of this knowledge is sufficient for many client situa-
tions; when it is insufficient, consultation is required. No other discipline has this varied knowledge,
explaining why attempts to substitute other disciplines for nursing have proved costly and ultimately unsuc-
cessful. Figure 1.1 illustrates this varied expertise.
The Bifocal Clinical Practice Model (Carpenito, 1983) represents situations that influence persons,
groups, and communities as well as the classification of these responses from a nursing perspective. The
situations are organized into five broad categories: pathophysiologic, treatment-related, personal, environ-
mental, and maturational (Figure 1.2). Without an understanding of such situations, the nurse will be
unable to diagnose responses and intervene appropriately.
Clinically, these situations are important to nurses. Thus, as nursing diagnoses evolved, nurses sought
to substitute nursing terminology for these situations; for example, Impaired Tissue Integrity for burns and
High Risk for Injury for dialysis. Nurses do not prescribe for and treat these situations (e.g., burns and dial-
ysis). Rather, they prescribe for and treat the responses to these situations.
The practice focus for clinical nursing is at the response level, not at the situation level. For example,
a client who has sustained burns may exhibit a wide variety of responses to the burns and the treatments.
Some responses may be predicted, such as High Risk for Infection; others, such as fear of losing a job, may
not be predictable. In the past, nurses focused on the nursing interventions associated with treating burns
rather than on those associated with the client’s responses. This resulted in nurses being described as “doers”
rather than “knowers”; as technicians rather than scientists.

Nursing Diagnoses and Collaborative Problems

The Bifocal Clinical Practice Model describes the two foci of clinical nursing: nursing diagnoses and col-
laborative problems.
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or poten-
tial health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable (NANDA, 1990). Collaborative problems are certain
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The Bifocal Clinical Practice Model 5

Nutrition Self-Care

Expert Expert

Novice Novice

rse

rse
an

ist

an

ist

era l
t

Wo cial
era l
t

Wo cial

r
r

Th sica
Th sica

pis
pis

rke
rke
ion

ion
ici

ici
Nu

Nu

So
So
ys

ys

y
y
trit

trit

Ph
Ph
Ph

Ph
Nu

Nu
Signs/Symptoms of Bleeding Pressure Ulcer Prevention

Expert Expert

Novice Novice
rse

an

era l
t
rse

an
ist

ist
Wo cial

Wo cial
Th sica
r

r
era l
t

pis
FIGURE 1.1
Th sica
pis

rke

rke
ici

ion

ion
ici
Nu

Nu
So

So
ys

y
ys
Knowledge of multidisciplines of selected
trit

trit
y

Ph
Ph
Ph

Ph
Nu

Nu
topics.

physiologic complications that nurses monitor to detect onset or changes of status. Nurses manage collaborative
problems using physician-prescribed and nursing-prescribed interventions to minimize the complications of the
events (Carpenito, 1997). Figure 1.3 illustrates the Bifocal Clinical Practice Model.
The nurse makes independent decisions for both collaborative problems and nursing diagnoses. The
difference is that in nursing diagnoses, nursing prescribes the definitive treatment to achieve the desired
outcome, while in collaborative problems, prescription for definitive treatment comes from both nursing
and medicine. Some physiologic complications (such as High Risk for Infection and Impaired Skin
Integrity) are nursing diagnoses because nurses can order the definitive treatment. In a collaborative prob-
lem, the nurse uses surveillance to monitor for the onset and change in status of physiologic complications,
and manages these changes to prevent morbidity and mortality. These physiologic complications are usually

Pathophysiological Treatment-related

Personal

FIGURE 1.2 Environmental Maturational

Examples of pathophysiologic, treatment-
related, personal, environmental, and
maturational situations.
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6 Introduction to Care Planning

FIGURE 1.3
Bifocal clinical practice model. (© 1987, Lynda
Juall Carpenito.)

related to disease, trauma, treatments, medications, or diagnostic studies. Thus, collaborative problems
can be labeled Potential Complication (specify); for example, Potential Complication: Hemorrhage or
Potential Complication: Renal Failure.
Monitoring, however, is not the sole nursing intervention for collaborative problems. For example, in
addition to monitoring a client with increased intracranial pressure, the nurse also restricts certain activi-
ties, maintains head elevation, implements the medical regimen, and continually addresses the client’s psy-
chosocial and educational needs.
The following are some collaborative problems that commonly apply to certain situations:

Situation Collaborative Problem

Myocardial Infarction Potential Complication (PC): Dysrhythmias

Craniotomy PC: Increased Intracranial Pressure

Hemodialysis PC: Fluid/Electrolyte Imbalance

Surgery PC: Hemorrhage

Cardiac Catheterization PC: Allergic Reaction

If the situation calls for the nurse to monitor for a cluster or group of physiologic complications, the col-
laborative problems may be documented as
PC: Cardiac
or
PC: Post-op: Urinary retention
PC: Hemorrhage
PC: Hypovolemia
PC: Hypoxia
PC: Thrombophlebitis
PC: Renal insufficiency
PC: Paralytic ileus
PC: Evisceration
A list of common collaborative problems grouped under conditions that necessitate nursing care
appears on the inside front and back covers. Not all physiologic complications, however, are collaborative problems.
Nurses themselves can prevent some physiologic complications such as infections from external sources
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The Bifocal Clinical Practice Model 7

(e.g., wounds and catheters), contractures, incontinence, and pressure ulcers. Thus, such complications fall
under the category of nursing diagnosis.

Nursing Interventions
Nursing interventions are treatments or actions that benefit a client by presenting a problem, reducing or
eliminating a problem, or promoting a healthier response. Nursing interventions can be classified as either
of two types: nurse-prescribed or physician-prescribed. Independent interventions are nurse-prescribed;
delegated interventions are physician-prescribed. Both types of interventions, however, require indepen-
dent nursing judgment. By law, the nurse must determine if it is appropriate to initiate an intervention
regardless of whether it is independent or delegated (Carpenito, 1997).
Carpenito (1987) stated that the relationship of diagnosis to interventions is a critical element in defin-
ing nursing diagnoses. Many definitions of nursing diagnoses focus on the relationship of selected inter-
ventions to the diagnoses. A certain type of intervention appears to distinguish a nursing diagnosis from a
medical diagnosis or other problems that nurses treat. The type of intervention distinguishes a nursing
diagnosis from a collaborative problem and also differentiates between actual risk/high risk and possible
nursing diagnoses. Table 1.2 outlines definitions of each type and the corresponding intervention focus.
For example, for a nursing diagnosis of Impaired Tissue Integrity related to immobility as manifested by
a 2-cm epidermal lesion on the client’s left heel, the nurse would order interventions to monitor the lesion
and to heal it. In another client with a surgical wound, the nurse would focus on prevention of infection
and promotion of healing. High Risk for Infection would better describe the situation than Impaired Tissue
Integrity. Nursing diagnoses are not more important than collaborative problems, and collaborative problems are not
more important than nursing diagnoses. Priorities are determined by the client’s situation, not by whether it is a nurs-
ing diagnosis or a collaborative problem.
A diagnostic cluster represents those nursing diagnoses and collaborative problems that have a high
likelihood of occurring in a client population. The nurse validates their presence in the individual client.
Figure 1.4 represents the diagnostic cluster for a client after abdominal surgery. Sections 1 and 2 contain
diagnostic clusters for medical and surgical conditions or goals.

Goals/Outcome Criteria
In a nursing care plan, goals (outcome criteria) are “statements describing a measurable behavior of
client/family that denote a favorable status (changed or maintained) after nursing care has been delivered”
(Alfaro, 1989). Outcome criteria help to determine the success or appropriateness of the nursing care plan.
If the nursing care plan does not achieve a favorable status even though the diagnosis is correct, the nurse
must change the goal or change the plan. If neither option is indicated, the nurse confers with the physi-
cian for delegated orders. Nursing diagnoses should not represent situations that require physician orders

TABLE 1.2 Differentiation Among Types of Diagnoses

Corresponding Client Outcome
Diagnostic Statement or Nursing Goals Focus of Intervention
Actual Diagnosis
Three-part statement including nursing Change in client behavior moving toward Reduce or eliminate problem
diagnostic label, etiology, and resolution of the diagnosis or improved
signs/symptoms status
Risk/High-Risk Diagnosis
Two-part statement including nursing Maintenance of present conditions Reduce risk factors to prevent an actual
diagnostic label and risk factors problem
Possible Diagnosis
Two-part statement including nursing Undetermined until problem is validated Collect additional data to confirm or rule
diagnostic label and unconfirmed out signs/symptoms or risk factors
etiology or unconfirmed defining
characteristics
Collaborative Problems
Potential or actual physiologic complication Nursing goals Determine onset or status of the problem
Manage change in status
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8 Introduction to Care Planning

Abdominal surgery (postoperative)

FIGURE 1.4
Diagnostic cluster for client recovering
from abdominal surgery.

for treatment. Otherwise how can nurses assume accountability for diagnosis and treatment? For example,
consider a client with a nursing diagnosis:
High Risk for Impaired Cerebral Tissue Perfusion related to effects of recent head injury and these
goals:
The client will demonstrate continued optimal cerebral pressure as evidenced by
• Pupils equally reactive to light and accommodation
• No change in orientation or consciousness
If this client were to exhibit evidence of increased intracranial pressure, would it be appropriate for the
nurse to change the goals? What changes in the nursing care plan would the nurse make to stop the cra-
nial pressure from increasing? Actually, neither action is warranted. Rather, the nurse should confer with
the physician for delegated orders to treat increased intracranial pressure. When the nurse formulates client
goals or outcomes that require delegated medical orders for goal achievement, the situation is not a nurs-
ing diagnosis but a collaborative problem. In this case, the client’s problem would be described better as a
collaborative problem:
Potential Complications: Increased Intracranial Pressure and the nursing goal:
The nurse will manage and minimize changes in increased intracranial pressure

Summary
The Bifocal Clinical Practice Model provides nurses with a framework to diagnose the unique responses
of a client and significant others to various situations. Clear definition of the two dimensions of nursing
enhances the use and minimizes the misuse of nursing diagnoses. The Bifocal Clinical Practice Model
describes the unique knowledge and focus of professional nursing.
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2 DOCUMENTATION OF NURSING CARE

Legal Issues of Nursing Documentation

Historically, nurses have believed that the more information a nurse has charted, the better his or her legal
defense will be in any litigation. Today nurses recognize that a comprehensive, streamlined documenta-
tion system actually can document more data in less time and space. Nursing documentation must be objec-
tive and comprehensive and must accurately reflect the status of the client and what has happened to him
or her. If legally challenged, the nursing records represent what reasonably prudent nurses chart, and
should demonstrate compliance with the institution’s policy.
Unfortunately, most hospitals and other agencies have not seriously examined what documentation actu-
ally requires. Many nurses have been taught to write as much as possible; they operate under the philosophy
“If it wasn’t charted, it wasn’t done.” Does poor charting represent poor care? Inherent in this question are
others: What is poor charting? By what standard is it poor? Does copious charting represent good care?
If a department of nursing does not establish specific policies for charting, then the charting in ques-
tion can be held to standards from another department of nursing or from expert testimony. Case law does
not determine the standards for nursing documentation, but instead passes a judgment regarding compli-
ance with a standard.

Attributes of Nursing Documentation

The most important purpose of documentation is to communicate to other members of the health care team the client’s
progress and condition. In addition, nursing documentation is important:
• To define the nursing focus for the client or group
• To differentiate the accountability of the nurse from that of other members of the health care team
• To provide the criteria for reviewing and evaluating care (quality improvement)
• To provide the criteria for client classification
• To provide justification for reimbursement
• To provide data for administrative and legal review
• To comply with legal, accreditation, and professional standard requirements
• To provide data for research and educational purposes
Defining documentation as always hand-written or typed as free text (in a computer) is problematic.
Documentation can take the form of a standard of care, a check marked on a form, or an initial on a flow
record. The accompanying policy should direct that there is to be minimal or no writing unless an unusual
or unsatisfactory situation has occurred.

Assessment
In assessment—the deliberate collection of data about a client, family, or group—the nurse obtains data by interview-
ing, observing, and examining. The two types of assessment are the initial screening interview and focus
assessment.

Initial Screening Interview

The screening interview has two parts: functional patterns and physical assessment. It focuses on determining the
client’s present health status and ability to function. Figure 2.1 shows a nursing admission database. Examples
of specific functional pattern assessment categories are as follows:
• Ability to bathe self
• Presence of confusion
• Spiritual practices
• Ability to control urination
9
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10 Introduction to Care Planning

FIGURE 2.1
Sample admission database. (Carpenito, L. J.
[2004] Nursing diagnosis: Application to clinical
practice [10th ed.]. Philadelphia: Lippincott
Williams & Wilkins.)

The physical examination uses the skills of inspection, auscultation, and palpation to assess areas such as
• Pulse
• Skin condition
• Muscle strength
• Lung fields
After completing and recording the screening assessment, the nurse analyzes the data and asks ques-
tions such as:
• Does the client have a problem that requires nursing interventions (e.g., assistance with ambulation)?
• Is the client at risk for developing a problem (e.g., pressure ulcers)?
• Does the client’s medical condition put him or her at high risk for complications (e.g., problems asso-
ciated with increased blood glucose level in diabetes mellitus)?
• Do the prescribed treatments put the client at high risk for complications (e.g., phlebitis from IV therapy)?
• Is additional data collection needed?

Focus Assessment
Focus assessment involves the acquisition of selected or specific data as determined by the nurse and the client or fam-
ily or as directed by the client’s condition (Carpenito, 1983). The nurse can perform a focus assessment during
the initial interview if the data suggest that he or she should ask additional questions. For example, on
admission the nurse would question most clients about eating patterns. He or she also would ask a client
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Documentation of Nursing Care 11

FIGURE 2.1
continued.
(continued on page 12)

with chronic obstructive pulmonary disease if dyspnea interferes with eating. This represents a focus assess-
ment because the nurse would not ask every client if dyspnea affects food intake.
The nurse does certain focus assessments—such as vital signs, bowel and bladder function, and nutri-
tional status—each shift for every client. (Section I presents a generic care plan for all hospitalized adults
that includes these routine focus assessments.) The nurse determines the need for additional focus assess-
ments based on the client’s condition. For example, in a postoperative client, the nurse assesses and mon-
itors the surgical wound and IV therapy.

Planning
The clinical purposes of documentation are to guide the caregiver and to record the client’s status or response. Directions
for nursing care originate in both nursing and medicine. Interventions prescribed by physicians are entered on
various forms (e.g., Kardex or treatment and medication administration records). Nurses prescribe both rou-
tine interventions and those specific to the client. Routine or predictive nursing interventions can be found
in nursing care standards. These client-specific interventions are listed in the addendum care plan.
Care plans (standards, addendum) serve the following purposes:
• They represent the priority set of diagnoses (collaborative problems or nursing diagnoses) for a client.
• They provide a “blueprint” to direct charting.
• They communicate to the nursing staff what to teach, observe, and implement.
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12 Introduction to Care Planning

FIGURE 2.1
continued.
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Documentation of Nursing Care 13

• They provide goals/outcome criteria for reviewing and evaluating care.

• They direct specific interventions for the client, family, and other nursing staff members to implement.
To direct and evaluate nursing care effectively, the care plan should include the following:
• Diagnostic statements (collaborative problems or nursing diagnoses)
• Goals (outcome criteria) or nursing goals
• Nursing orders or interventions
• Evaluation (status of diagnosis and client progress)

Diagnostic Statements
Diagnostic statements can be either collaborative problems or nursing diagnoses. Refer to Chapter 1, The
Bifocal Clinical Practice Model, for information on these two types of diagnostic statements.

Goals/Outcome Criteria
Client goals, or outcome criteria, are statements that describe a measurable behavior of the client or fam-
ily, denoting a favorable status (changed or maintained) after delivery of nursing care (Alfaro, 2002). They
serve as standards for measuring the care plan’s effectiveness. Goals/outcome criteria for nursing diagnoses
should represent favorable statuses that the client can achieve or maintain through nursing-prescribed (independent)
interventions (Carpenito, 1992; Carpenito-Moyet, 2008). If the client is not achieving goals, the nurse must
reevaluate the diagnosis and revise the goals and the plan or collaborate with a physician.
When the nurse collaborates with the physician, the diagnosis is a collaborative problem, not a nurs-
ing diagnosis. For example, if a client with a collaborative problem of Potential Complication: Dysrhythmia
experiences premature ventricular contractions, the nurse would not change the nursing care plan, but
would instead, initiate physician-prescribed interventions. Collaborative problems should not have client
goals (outcome criteria). Any goals or outcome criteria written for collaborative problems would need to represent
the criteria for evaluating both nursing and medical care. Physiologic stability is the overall goal for collaborative
problems. Such measures are represented through nursing goals.

Nursing Interventions
As written in Chapter 1, there are two types of nursing interventions: nurse-prescribed and physician-
prescribed. Care plans should contain nurse-prescribed interventions. Care plans should not contain directions
for nurses regarding delegated (physician-prescribed) treatments. Instead, nurses enter physicians’ orders on care and
treatment records, Kardexes, and medication administration records. For this reason, the care plans presented in
Unit II list only nurse-prescribed (independent) interventions. At the end of the Collaborative Problems
section in each care plan, a section titled Related Physician-Prescribed Interventions provides these
interventions as additional information. This chapter later explains the relationship of standards of care,
physician-prescribed interventions, and critical pathways.
In the care plans, the interventions listed under nursing diagnoses generally consist of these types
(Alfaro-LeFevre, 2002):
• Performing activities for the client or assisting the client with activities
• Performing nursing assessments to identify new problems and to determine the status of existing
problems
• Teaching the client to help him or her gain new knowledge about health or the management of a disorder
• Counseling the client to make decisions about his or her own health care
• Consulting with other health care professionals
• Performing specific actions to remove, reduce, or resolve health problems
In contrast, the interventions listed under collaborative problems focus primarily on the following:
• Monitoring for physiologic instability
• Consulting with a physician to obtain appropriate interventions
• Performing specific actions to manage and to reduce the severity of the event
• Explaining the problem and the rationale for actions
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14 Introduction to Care Planning

Care Planning Systems

Standards of Care
Standards of care are detailed guidelines that represent the predicted care indicated in a specific situation.
Standards of care should represent the care that nurses are responsible for providing, not an ideal level of
care. The nurse cannot hope to address all or even most of the problems that a client may have. Rather, the nurse
must select those problems that are the most serious or most important to the client. Ideal standards that are un-
realistic only frustrate nurses and hold them legally accountable for care that they cannot provide. Nurses
must create realistic standards based on client acuity, length of stay, and available resources.
A care planning system can contain three levels of directions:
• Level I—Generic Unit Standards of Care
• Level II—Diagnostic Cluster or Single Diagnosis Guidelines
• Level III—Addendum Care Plans
Level I Standards of Care predict the generic care that all or most individuals or families in a unit will
need. Examples of generic unit standards of care are medical, surgical, oncologic, pediatric, postpartum,
operating room, emergency room, mental health unit, rehabilitation unit, and newborn nursery. Figure
2.2 presents a diagnostic cluster for most hospitalized adults. The Generic Medical Care Plan at the begin-
ning of Section 1 and the Generic Surgery Care Plan at the beginning of Section 2 are Level I standards.
Because they apply to all clients, nurses do not need to write the nursing diagnoses or collaborative prob-
lems associated with the generic standard of care on an individual client’s care plan. Instead, institutional
policy can specify that the generic standard will be implemented for all clients. Documentation of the
generic standard is discussed later in this chapter.
Level II guideline care plans contain a diagnostic cluster or a single nursing diagnosis or collaborative
problem. A diagnostic cluster is a set of nursing diagnoses and collaborative problems that have been pre-
dicted to be present and of high priority for a given population. Unit II contains Level II care plans orga-

Collaborative Problems
Potential Complication: Cardiovascular
Potential Complication: Respiratory

Nursing Diagnoses
Anxiety related to unfamiliar environment, routines, diagnostic
tests and treatments, and loss of control
Risk for Injury related to unfamiliar environment and physi-
cal/mental limitations secondary to condition, medications,
therapies, and diagnostic test
Risk for Infection related to increased microorganisms in envi-
ronment, the risk of person-to-person transmission, and inva-
sive tests and therapies
Self-Care Deficit related to sensory, cognitive, mobility,
endurance, or motivation problems
Risk for Imbalanced Nutrition: Less Than Body Requirements
related to decreased appetite secondary to treatments, fatigue,
environment, changes in usual diet, and increased
protein/vitamin requirements for healing
Risk for Constipation related to change in fluid/food intake, rou-
tine and activity level, effects of medications, and emotional
stress
Disturbed Sleep Pattern related to unfamiliar or noisy environ-
ment, change in bedtime ritual, emotional stress, and change
in circadian rhythm
Risk for Spiritual Distress related to separation from religious
support system, lack of privacy, or inability to practice spiritual
rituals
Interrupted Family Processes related to disruption of routines,
change in role responsibilities, and fatigue associated with FIGURE 2.2
increased workload and visiting hour requirements Level I diagnostic cluster for hospitalized
adults.
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Documentation of Nursing Care 15

nized using diagnostic clusters. Those diagnoses indicated as primary have been reported to be managed
by nurses 75%–100% of the time. Those diagnoses that are indicated to be important are managed
50%–74% of the time. Refer to the description of the Validation Study, p. x. Examples of Level II single-
diagnosis standards are High Risk for Impaired Skin Integrity, High Risk for Violence, and PC:
Fluid/Electrolyte Imbalances.
Although standards of care do not have to be part of the client’s record, the record should specify what
standards have been selected for the client. The problem list serves this purpose. The problem list repre-
sents the priority set of nursing diagnoses and collaborative problems for an individual client. Figure 2.3
presents a sample problem list. Next to each diagnosis, the nurse would indicate where the directions for
the care can be found—on a standardized form or on the addendum plan. The nurse can use the last col-
umn to indicate client progress.

Priority Set of Diagnoses

Nurses cannot address all or even most of the nursing diagnoses and collaborative problems in clients and families.
Priority diagnoses are those nursing diagnoses and collaborative problems for which nursing resources will be directed
toward goal achievement. They take precedence over other nursing diagnoses/collaborative problems that

Nursing Problem List/Care Plan

Nursing Diagnosis/Collaborative Problem Status Standard Addendum Evaluation of Progress

FIGURE 2.3
Nursing problem list and care
plan.
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16 Introduction to Care Planning

may be important but not priorities (Carpenito, 1995). In acute care settings, priority diagnoses are those
nursing diagnoses or collaborative problems that
1. Are associated with the primary medical or surgical condition
2. If not managed now will deter progress or negatively affect functional status
Important but nonpriority nursing diagnoses or collaborative problems need to be referred to the client for manage-
ment after discharge. A referral to a community resource may be indicated. For example, the nurse can refer
a woman with peripheral vascular disease who wants to quit smoking to a smoking cessation program in
the community.
The problem list in Figure 2.4 illustrates three priority diagnoses in addition to those on the Post-
Operative Standard of Care.

Addendum Care Plans

An addendum care plan represents additional interventions to be provided for the client. Nurses can add
these specific interventions to a Level II guideline care plan or may associate them with additional prior-
ity nursing diagnoses or collaborative problems not included on the standardized plan.

FIGURE 2.4
Sample problem list and
addendum care plan.
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Documentation of Nursing Care 17

The initial care of most hospitalized clients can be directed responsibly using standards of care. With
subsequent nurse–client interactions, specific data may warrant specific addendum additions to the client’s
care plan to ensure holistic, empathic nursing care. Figure 2.4 presents a problem list and addendum care
plan for a client recovering from gastric surgery. In addition to the diagnostic cluster in the postoperative
standard of care, this client has three addendum diagnoses. High Risk for Impaired Skin Integrity is being
managed with interventions from a standard for this diagnosis. Documentation will be completed at each
shift on the flow record. Impaired Swallowing is being treated with generic interventions and with adden-
dum intervention specifying foods that this client can tolerate. The last diagnosis, Impaired Physical
Mobility, involves only addendum interventions prescribed to increase the client’s motivation and to pro-
mote correct ambulation techniques.

Critical Pathways
The concept of critical pathways has been a well-known management tool for many years in such disci-
plines as economics and engineering, in which they are organized as a timeline grid to monitor the progress
of a project. Critical pathways in nursing were developed at the New England Medical Center in 1985 by
Kathleen Bower and Karen Zander. Since then, numerous versions of critical pathways have been devel-
oped in hundreds of facilities under various names such as CareMap, critical paths, Collaborative Action
Track, and Milestone Action Plans.
Critical pathways “are based on the process of anticipating and describing in advance the care clients,
within the specific case types, require and then comparing the actual status of the client to that anticipated”
(Bower, 1993). They are developed on selected client populations with the participation of the disciplines
involved in the care. Each discipline is asked to outline the usual anticipated care requirements and the out-
comes (Bower, 1993). So, before creating a critical pathway, nurses must identify their standard of care for
the population. A standard of care for a population should include

1. The priority set of nursing diagnoses and collaborative problems predicted to need nursing interven-
tions during the expected length of stay
2. Realistic, achievable outcomes
3. Realistic, pertinent interventions

Critical pathways are multidisciplinary; standards of care may or may not be. Nursing diagnoses and col-
laborative problems are excellent language for other disciplines such as respiratory therapy, physical ther-
apy, social service, nutritional therapy, and so on. After the standard of care is established for nursing, it
could be passed on to other disciplines for addition of interventions specific to them (Carpenito, 1995).
Figure 2.5 illustrates a section from a multidisciplinary care plan for a client with a fractured hip.
The additional physician orders for the client usually are not indicated on the standard of care, because
the problems in the standard are nursing diagnoses and collaborative problems. Physician standard orders
are reflected on the critical pathway. After nursing and other disciplines have completed the standard of
care, the critical pathway can be formulated.

Nursing Diagnosis: Impaired Physical Mobility related to pain,

stiffness, fatigue, restrictive equipment,
and prescribed activity restrictions.

Goal: The client will increase activity to a level

consistent with abilities

Interventions:

FIGURE 2.5
Sample multidisciplinary care plan for a
client after a total hip replacement.
(Carpenito, L. J. [2004]. Nursing diagno-
sis: Application to clinical practice
[10th ed.]. Philadelphia: Lippincott
Williams & Wilkins.)
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18 Introduction to Care Planning

Critical Pathway Format

Critical pathways can be developed for client populations using the medical diagnosis, the surgical or diag-
nostic procedure, or a therapy such as ventilator dependent or chemotherapy (Bower, 1993). The critical
pathway outlines the anticipated care requirements and the outcomes to achieve within a pre-established
timeframe.
The outcomes identified on a critical pathway can be those linked to collaborative problems and nurs-
ing diagnoses identified for the population. Another approach is to identify the discharge criteria for the
population. In either case, the client is evaluated daily for progress. Figure 2.6 represents a CareMap from
the Center for Case Management, which illustrates problem statements linked with outcomes. The lower
portion of the CareMap describes the staff tasks on a timeline.

Linking Standards of Care to Critical Paths

The care plans in this book represent care for a population. As a result of the validation work described on
p. xiii, the nursing diagnoses and collaborative problems treated frequently by nurses have been established.
These findings will assist nurses in establishing the standard from which critical pathways are derived.
The remainder of this section will outline the creation of a standard of care and critical pathway from
the care plan for an individual undergoing a hip replacement. Table 2.1 illustrates the critical pathway
derived from the standard of care. On the basis of the findings of the validation study, only those nursing
diagnoses and collaborative problems reported to be monitored for or treated more than 75% of the time
are included on the standard. In addition, outcomes that are achievable during the expected length of stay
and interventions to achieve these outcomes are illustrated online.

Care Plans and Critical Paths

As discussed earlier, critical pathways offer an at-a-glance timeline to evaluate the progress of a client in
a population. Critical pathways frequently do not accommodate additional nursing diagnoses or collabo-
rative problems (addendum diagnoses) that are present and need nursing interventions. These addendum
diagnoses can delay client progress if not addressed. For example, a woman scheduled for a hip replace-
ment also has diabetes mellitus. This would necessitate monitoring for the collaborative problem, “PC:
Hypo/Hyperglycemia.” How will the nurse communicate this problem to other nurses with a critical
path? One option is to write this additional problem under the problem list in the critical path and to
insert the monitoring of blood glucose levels under the assessment section. This would work if the inter-
ventions were brief, such as “monitor blood glucose levels.” However, what if this woman is also confused
before surgery? This would necessitate the addition of Disturbed Thought Processes to the problem list.
The interventions for this addendum diagnosis are not brief. A problem list/care plan can provide the
solution. Figure 2.7 illustrates a problem list/care plan for this woman. A detailed explanation of problem
lists can be found online.

Documentation and Evaluation

Care plans represent documentation of the nursing care planned for a client. They also reflect the status
of a diagnosis: active, resolved, or ruled out. The documentation of care delivered and the client’s status or
response after care are recorded on specific forms, including:
• Graphic records
• Flow records
• Progress notes
• Teaching records
• Discharge planning/summary
The nurse is responsible for evaluating a client’s status and progress to outcome achievement daily.
Evaluation of the client’s status and progress is different for collaborative problems versus nursing diag-
noses. For nursing diagnoses, the nurse will:

(text continues on page 23)

 11075-02_Ch02rev.qxd

CareMapTM: Congestive Heart Failure

Benchmark Quality Criteria

8/7/08

Problem
10:30 AM
Page 19

if

and hospitilization

FIGURE 2.6
Sample CareMap. (From the Center for Case Management, South Natick, MA. CareMap is a registered trademark of the Center for Case
Management; used with permission.)
(continued on page 20)
Documentation of Nursing Care
19
 20
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Staff Tasks
8/7/08

Intake and output Intake and output Intake and output Intake and output
Introduction to Care Planning
10:30 AM

Intake and output Intake and output

Intake and output

Page 20

FIGURE 2.6
continued.
 11075-02_Ch02rev.qxd

TABLE 2.1 Critical Pathways for a Client Undergoing a Total Hip Replacement
Intermediate Goals Outcomes
8/7/08

Nursing Diagnosis/
Collaborative Problem Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8
Potential complication: Nurse will manage → → → → → → State signs and symptoms
Fat emboli and minimize that must be reported to
10:30 AM

Compartmental syndrome vascular and joint a health care professional.

Hemorrhage complications.
Joint displacement
Sepsis
Thrombosis
Page 21

High Risk for Infection Will exhibit → → → → → Demonstrate healing with

wound heal- evidence of intact, approx-
ing free of imated wound edges or
infection granulation tissue

Impaired Physical Mobility Will relate the pur- Will do strength- → Will demonstrate → → → Regain mobility while adher-
pose of strength- ening exercises use of assistive ing to weight-bearing
ening exercises device restrictions using an assis-
tive device

Pain Will report satisfac- → Will report a less- Will report relief → → → Report progressive reduction
tory pain relief ening of pain from PO med- of pain and an increase in
ications activity

High Risk for Injury Will identify factors → → → → → → Describe risk factors for
that increase injury in home
risk of injury;
will describe
appropriate safety
measures

High Risk for Impaired Skin Will demonstrate → → → → → → Demonstrate skin integrity
Integrity skin integrity free free of pressure ulcers
of pressure ulcers

High Risk for Ineffective Will communicate → → → → Demonstrate skills → Describe activity restrictions
Therapeutic Regimen questions and needed for Describe a plan for resuming
Management concerns activities of daily ADLs
living (ADLs)
(continued on page 22)
Documentation of Nursing Care
21
 22
11075-02_Ch02rev.qxd

TABLE 2.1 Critical Pathways for a Client Undergoing a Total Hip Replacement (continued)
8/7/08

Timeline OR Day POD #1 POD #2 POD #3 POD #4 POD #5 POD #6 POD #7 POD #8
Consults OT
PT
Introduction to Care Planning
10:30 AM

Home Care

Test Post-op x-ray Hct; SMA6 → → → PT/PIT → → → →

PT/PIT
Page 22

Treatments Hemovac drain IV → D/C Hemovac → D/C IV → → → D/C Staples

D/C dressing

Medication Antibiotic pre-op Antibiotic IM PO pain meds. → Anticoagulant → → → Prescription

pain meds. D/C anticoagulant
Anticoagulant

Diet As ordered → → → As ordered → → →

Activity Bedrest with abduction pil- OOB/chair Weight bear as → Weight bear as Crutches Stairs with assist → →
low; maintain alignment tolerated; tolerated; Independent
transfer/assist transfer/assist with walker
Ambulate/walker Ambulate/walker

Assessments Post-op assessments Assess Ace → → Turn q 2 hrs → → → →

wrap Monitor incision
Monitor neuro- Monitor neuro-
vascular vascular status
status Monitor tissue
Monitor tissue integrity
integrity

Teaching S/S neurovascular compro- Post-op → → Evaluate Pt/S.O. → → → Written instructions

mise; reinforce activity exercises understanding
and safety measures

Discharge Social work prn → → → → → Written instructions

Planning Home care prn
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Documentation of Nursing Care 23

FIGURE 2.7
Nursing problem list/care plan.

• Assess the client’s status.

• Compare this response to the outcome criteria.
• Conclude if the client is progressing to outcome achievement.
The nurse can record this evaluation on a flow record as
7 AM–3 PM
Comfort
Acute Comfort Report satisfaction relief from measures or on a progress note as
Sub. The medication relieved my pain well. It is easier to move and cough.
Eval. Pain controlled; continue plan.
Not all nursing diagnoses require a progress note to record evaluation. A well-designed flow record
can be used.
For collaborative problems, the nurse will:
• Collect selected data.
• Compare the data to the established norms.
• Judge if the data are within an acceptable range.
The nurse can record the assessment data for collaborative problems on flow records. Progress notes can
be used if the findings are significant, followed by the nursing management of the situation. The last col-
umn of Figure 2.3 represents the place where the nurse can document client progress for each diagnosis
on the problem list. The frequency of this documentation will be determined by the institution (e.g.,
q 24 h). If a client has not improved or has worsened an I* or N* is used. In addition, a progress note is
required to record the nursing actions undertaken.
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24 Introduction to Care Planning

So, the evaluation for nursing diagnoses is focused on progress to achievement of client outcome,
whereas the evaluation for collaborative problems is focused on the client’s condition compared with estab-
lished norms.

Discharge Planning
Discharge planning is a systematic process of appraisal, preparation, and coordination done to facilitate provision of
health care and social services before and after discharge. Discharge planning can be categorized as standard or
addendum.
Standard discharge planning includes the teaching deemed necessary based on the client’s specific medical or sur-
gical condition. The standard of care usually can address the content to be taught under two nursing diag-
noses: Risk for Ineffective Management of Therapeutic Regimen, and Risk for Impaired Home Maintenance
Management. Standard discharge planning is the responsibility of the professional nurse caring for the client
or family.
Addendum discharge planning requires coordinated and collaborative action among health care providers within
the institution and in the community at large. Multidisciplinary actions may be indicated. A discharge coordinator
or a case manager should coordinate this type of discharge planning.

I. Planning (initiate on admission)

II. Discharge Criteria and Instructions

FIGURE 2.8
Discharge planning and
summary record.
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Documentation of Nursing Care 25

Staff nurses usually do not have the time or resources available for addendum discharge planning.
However it is the staff nurse who refers high-risk clients or families to the discharge coordinator.
The goal of discharge planning is to identify the specific needs for maintaining or achieving maximum
function after discharge. The discharge needs of clients and families can result in two types of nursing actions:
• Teaching the client or family how to manage the situation at home
• Referring the client or family to support services (e.g., community nurses, physical therapists, or self-
help groups) for assistance with management at home
All unresolved outcome criteria on the problem list require either teaching for self-management or refer-
rals before discharge.
Discharge planning should begin at admission. After the admission assessment, the nurse must ana-
lyze the data to identify if the client or family needs addendum discharge planning and referrals. Figure 2.8
presents questions that can help the nurse identify high-risk clients and families. These questions can be
placed either as a section at the end of the admission assessment form, as illustrated in Figure 2.1, or as a
section on a combined discharge planning and summary record as in Figure 2.8. High-risk clients and fam-
ilies require a referral to the discharge coordinator at admission.
Certain events that may not be predicted on admission also necessitate referral to a discharge coordi-
nator. Some examples follow:
• Newly diagnosed chronic disease; terminal illness
• Prolonged recuperation after illness or surgery
• Complex home care regimens
• Insufficient or no health insurance
• Emotional instability

III. Discharge Summary

FIGURE 2.8
continued.
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26 Introduction to Care Planning

Discharge Summary
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends that a dis-
charge summary represent instructions given, referrals, client status, and the client’s understanding of the
instructions. The nurse can use progress notes to record this information; however, a more efficient sys-
tem for recording the discharge summary can be designed. This record could be adapted with specific out-
comes related to the medical or surgical condition. For example, a preprinted discharge summary record
for a postoperative client could include these items:
• The client will correctly describe wound care measures.
• The client will state signs and symptoms that must be reported to a health care professional: fever,
chills, redness or drainage of wound, and increasing pain.
A systematic, efficient discharge planning program can promote continuity of care by identifying a client’s
discharge needs early. Early identification of discharge needs also may help to eliminate unnecessary hos-
pital days and unnecessary readmissions.

Summary
The development of an efficient, professional nursing documentation system is possible within the scope
of existing standards of practice. The elimination of repetitive narrative charting on progress notes can
reduce the total time spent in charting and produce a more accurate and useful representation of profes-
sional practice and client or family response. A streamlined documentation system that integrates the nurs-
ing process from admission to discharge with the designated charting requirements also presents the nurse
with an optimum defense in the event of litigation proceedings and legal challenges.
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3 11 STEPS TO CARE PLANNING

Care plans have one primary purpose: to provide directions for the nursing staff for a particular client. For
students and nurses inexperienced in caring for a client with a particular condition or after a certain surgi-
cal procedure, these directions (care plan) need to be detailed. For nurses experienced in caring for people
with a particular condition or after a certain surgical procedure, these directions (care plan) will be limited
to only those specific interventions that are different for this particular client.
For example, a client who has diabetes mellitus is having abdominal surgery. An inexperienced nurse
or student will need to refer to the generic care plan for a surgical client and an additional section on
hypo/hyperglycemia (low or high blood glucose). An experienced nurse will not need to read a care plan
for abdominal surgery but will need to know that the client also has diabetes and will need blood glucose
monitoring. In hospitals and other health care agencies, general care plans for certain conditions or surgi-
cal procedures are usually in a computer or pre-printed to use as a reference. Other problems that are not
on the general care plan are added individually.

Author’s note: Some hospitals have problem lists for each client. This would list problems associated with general surgery and
an additional problem of hyper/hypoglycemia.

Step 1: Assessment
If you interview your assigned client before you write your care plan, complete your assessment using the
form recommended by your faculty. If you need to write a care plan before you can interview the client,
go to Step 2. After you complete your assessment, circle all information that points to client strengths.
Write all the strengths on an index card.

Author’s note: Strengths are factors that will help the client recover, cope with stressors, and progress to his or her original
health prior to hospitalization, illness, or surgery. Examples of strengths include:
• Positive spiritual framework
• Positive support system
• Ability to perform self-care
• No eating difficulties
• Effective sleep habits
• Alert, good memory
• Financial stability
• Relaxed most of the time
Highlight all information that points to client strengths. Write all the strengths on the back of the
index card.

Author’s note: Risk factors are situations, personal characteristics, disabilities, or medical conditions that can hinder the client’s
ability to heal, cope with stressors, and progress to his or her original health prior to hospitalization, illness, or
surgery. Examples of risk factors include:
• Obesity
• Fatigue
• Limited ability to speak or understand English
• Memory problems
• Hearing problems
• Self-care problems before hospitalization
• Difficulty walking
• Financial problems
• Tobacco use
27
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28 Introduction to Care Planning

• Alcohol problem
• Moderate to high anxiety most of the time
• Frail, elderly
• Presence of chronic diseases
Arthritis Depression
Diabetes mellitus Cardiac disorder
HIV Pulmonary disease
Multiple sclerosis

Step 2: Same Day Assessment

If you have not completed a screening assessment of your assigned client, determine the following as soon
as you can by asking the client, family, or nurse assigned to your client.
• Before hospitalization:
• Could the client perform self-care?
• Did the client need assistance?
• Could the client walk unassisted?
• Did the client have memory problems?
• Did the client have hearing problems?
• Did the client smoke cigarettes?
• What conditions or diseases does the client have that make him or her more vulnerable to:
• Falling
• Infection
• Nutrition/fluid imbalances
• Pressure ulcers
• Severe or panic anxiety
• Physiological instability (e.g., electrolytes, blood glucose, blood pressure, respiratory function, heal-
ing problems)
• When you meet the assigned client, determine if any of the following risk factors are present:
• Obesity
• Impaired ability to speak/understand English
• Communication difficulties
• High anxiety
Write significant data on the index card. Go to Step 3.

Author’s note: In some nursing programs, students do not have the opportunity to see or assess their assigned client prior to
the clinical day. Therefore they must assess the client on their first clinical day.

Step 3: Create Your Initial Care Plan

Why is your client in the hospital? Go to the index in this book and look up the medical condition or sur-
gical procedure. If you find the condition or surgical procedure, go to Step 4.
If the condition your client is hospitalized for is not in the index, refer to the generic medical care plan
at the beginning of Section 1. If your client had surgery, refer to the generic surgical or ambulatory care
plan at the beginning of Section 2.

Step 4: Additional Problems

If the medical condition or risk factor puts your client at high risk for a physiological complication such as
electrolyte imbalances or increased intracranial pressure or for nursing diagnoses such as Impaired Skin
Integrity, Risk for Infection Transmission, or Self-Care Deficit, go to the individual indexes for collabora-
tive problems and/or nursing diagnoses. You will find the problem or nursing diagnoses there. Go to Step 5.

Author’s note: These individual indexes provide numerous options when your assigned client has risk factors and medical con-
ditions in addition to the primary reason he or she is hospitalized.
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11 Steps to Care Planning 29

Step 5: Review Standard Plan

• Review each section of the care plan. Review your client’s risk factors on your index card.
• Review the collaborative problems listed. These are the physiological complications that you need to
monitor. Do not delete any because they all relate to the condition or procedure that your client has
had. You will need to add how often you should take vital signs, record intake and output, change
dressings, etc. Ask the nurse you are assigned with for these times or review the Kardex, which may
also have the time frames.
• Review each intervention for collaborative problems. Are any interventions unsafe or contraindicated
for your client? For example, if your client has edema and renal problems, the fluid requirements may
be too high for him or her.

Author’s note: Review the collaborative problems on the standard plan. Also review all additional collaborative problems that
you found in the separate index that relate to your assigned client.

Step 6: Review the Nursing Diagnoses

on the Standard Plan
Review each nursing diagnosis on the plan.
• Does it apply to your assigned client?
• Does your client have any risk factors (see your index card) that could make this diagnosis worse?
An example on the Generic Medical Care Plan is, Risk for Injury related to unfamiliar environment and phys-
ical or mental limitations secondary to condition, medication, therapies, or diagnostic tests.
Now look at the list of risk factors for your assigned client. Can any of the factors listed contribute to
the client sustaining an injury? For example, is he or she having problems walking or seeing? Is he or she
experiencing dizziness?
If your client has an unstable gait related to peripheral vascular disease (PVD), you would add the fol-
lowing to the diagnosis: Risk for Injury related to unfamiliar environment and unstable gait secondary to PVD.

Author’s note: If you know your client has PVD, but you do not know how this can affect functioning, look up the diagnosis in
this book (or another textbook) and review what problems PVD causes. Examples include unstable gait, poor
circulation to the legs, and risk for injury.

Interventions
Review the intervention for each nursing diagnosis:
• Are they relevant for your client?
• Will you have time to provide them?
• Are any interventions not appropriate or contraindicated for your assigned client?
• Can you add any specific interventions?
• Do you need to modify any interventions because of risk factors (see index card)?

Author’s note: Remember that you cannot individualize a care plan for a client until you spend time with him or her, but you
can add and delete any inappropriate interventions based on your preclinical knowledge of this client (e.g., med-
ical diagnosis, coexisting medical conditions).

Goals/Outcome Criteria
Review the goals listed for the nursing diagnosis:
• Are they pertinent to your client?
• Can the client demonstrate achievement of the goal on the day you provide care?
• Do you need more time?
Delete goals that are inappropriate for your client. If the client will need more time to meet the goal,
add “by discharge.” If the client can accomplish the goal by a certain day, write “by (insert date)” after
the goal.
11075-03_Ch03rev.qxd 8/7/08 10:31 AM Page 30

30 Introduction to Care Planning

Hint: Faculty and references may have different words to describe goals. Ask your faculty which ter-
minology they use.
Using the same diagnosis, Risk for Injury related to unfamiliar environment and physical or mental limita-
tions secondary to the condition, therapies, and diagnostic tests, consider this goal:
The client will not sustain an injury.

Indicators
• Identify factors that increase risk of injury.
• Describe appropriate safety measures.
If it is realistic for your client to achieve all the goals on the day of your care, you should add the date to all
of them. If your client is confused, you can add the date to the main goal, but you would delete all the indi-
cators because the client is confused. Or you could modify the goal by writing:
Family member will identify factors that increase the client’s risk of injury.

Author’s note: Consult with clinical faculty to assure this is acceptable.

Step 7: Prepare the Care Plan (Written or Printed)

You can prepare the care plan by:
• Typing a care plan from this book into your word processor then deleting or adding specifics for your
client (use another color for additions/deletions)
• Photocopying a care plan from this book then adding or deleting specifics for your client
• Writing the care plan

Author’s note: Ask your faculty person what options are acceptable. Using different colors or fonts allows him or her to clearly
see your analysis. Be prepared to provide rationales for why you added or deleted items.

Step 8: Initial Care Plan Completed

Now that you have a care plan of the collaborative problems and nursing diagnoses, which are associated
with the primary condition for which your client was admitted? If your assigned client is a healthy adult
undergoing surgery or was admitted for an acute medical problem and you have not assessed any signifi-
cant risk factors in Step 1, you have completed the initial care plan. Go to Step 10.

Step 9: Additional Risk Factors

If your client has risk factors (on the index card) that you identified in Steps 1 and 2, evaluate if these risk
factors make your assigned client more vulnerable to develop a problem. The following questions can help
to determine if the client or family has additional diagnoses that need nursing interventions:
• Are additional collaborative problems associated with coexisting medical conditions that require moni-
toring (e.g., hypoglycemia)?
• Are there additional nursing diagnoses that, if not managed or prevented now, will deter recovery or
affect the client’s functional status (e.g., High Risk for Constipation)?
• What problems does the client perceive as priority?
• What nursing diagnoses are important but treatment for them can be delayed without compromising
functional status?
You can address nursing diagnoses not on the priority list by referring the client for assistance after dis-
charge (e.g., counseling, weight loss program).

Author’s note: Priority identification is a very important but difficult concept. Because of shortened hospital stays and because
many clients have several chronic diseases at once, nurses cannot address all nursing diagnoses for every client.
Nurses must focus on those for which the client would be harmed or not make progress if they were not
addressed. Ask your clinical faculty to review your list. Be prepared to provide rationales for your selections.
11075-03_Ch03rev.qxd 8/7/08 10:31 AM Page 31

11 Steps to Care Planning 31

Step 10: Evaluate the Status of Your Client

(After You Provide Care)
Collaborative Problems
Review the nursing goals for the collaborative problems:
• Assess the client’s status.
• Compare the data to established norms (indicators).
• Judge if the data fall within acceptable ranges.
• Conclude if the client is stable, improved, unimproved, or worse.
Is your client stable or improved?
• If yes, continue to monitor the client and to provide interventions indicated.
• If not, has there been a dramatic change (e.g., elevated blood pressure, decreased urinary output)?
Have you notified the physician or advanced practice nurse? Have you increased your monitoring of
the client?
Communicate your evaluations of the status of collaborative problems to your clinical faculty and to the
nurse assigned to your client.

Nursing Diagnosis
Review the goals or outcome criteria for each nursing diagnosis. Did the client demonstrate or state the
activity defined in the goal? If yes, then communicate (document) the achievement on your plan. If not and
the client needs more time, change the target date. If time is not the issue, evaluate why the client did not
achieve the goal. Was the goal:
• Not realistic because of other priorities
• Not acceptable to the client

Author’s note: Ask your clinical faculty where to document evaluation of goal achievement.

Step 11: Document the Care on the Agency’s Forms,

Flow Records, and Progress Notes
Author’s note: Ask your clinical faculty person where you should document the client evaluation after you have provided care.
11075-04_Ch04rev.qxd 8/7/08 10:31 AM Page 32

4 THE ILL ADULT: ISSUES AND RESPONSES

Illness, trauma, hospitalization, diagnostic studies, and treatments can precipitate various client responses.
Depending on the situation, the client’s individual personality, and other factors, these responses may
include:
• Fear
• Anxiety
• Anger
• Denial
• Grief
• Apathy
• Confusion
• Hopelessness
• Loss of control
The nurse, as the primary presence 24 hours a day, and as the practitioner of the science and art of nursing,
represents the optimal health care provider for an ill client and his or her support persons (family members
or significant others).
According to Henderson and Nite (1960), “Nursing is primarily assisting individuals (sick or well) with
those activities contributing to health or its recovery (or to a peaceful death) that they perform unaided
when they have the necessary strength, will, or knowledge.” Nursing also helps clients carry out prescribed
therapy and become independent of assistance as soon as possible (Henderson & Nite, 1960).

Stress and Adaptation

According to Hoskins (2000), “Stress is a state produced by a change in the environment that is perceived
as challenging, threatening or damaging to the person’s dynamic equilibrium.” Lazarus and Folkman
(1980) have developed a theory of stress that focuses on the interaction or transaction between the person
and the external environment. Lazarus and Monat (1977) describe coping as the psychological and behav-
ioral activities done to master, tolerate, or minimize external or internal demands and conflicts. According
to Miller (1999), individuals “who have a rigid set or narrow range of coping skills are at more risk for
impaired coping because different types of coping strategies are effective in different situations.”
Every person has a concept of self that encompasses feelings about self-worth, attractiveness, lovabil-
ity, and capabilities. Everyone also has implicit or explicit goals. Illness, other disruptions to health, and
associated treatments can negatively affect a person’s self-concept and ability to achieve goals. These neg-
ative effects are losses, which precipitate grieving. The extent of a person’s grief response is directly related
to the extent of interference in goal-directed activity and the significance of the goal.

Coping Strategies
Adaptive and effective coping strategies produce these results (Visotsky, 1961):
• Distress is kept at or returned to a manageable level.
• Hope is maintained or renewed.
• Positive self-esteem is maintained or restored.
• Cooperative relationships are maintained.
Cohen and Lazarus (1983) have described five modes of coping:
• Information-seeking
• Direct action
• Inhibition of actions
32
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*** START OF THE PROJECT GUTENBERG EBOOK BERTRAND OF

BRITTANY ***
 BERTRAND
OF BRITTANY

BY
WARWICK DEEPING
AUTHOR OF
“A WOMAN’S WAR” “THE SLANDERERS”
“BESS OF THE WOODS” ETC.

NEW YORK AND LONDON

HARPER & BROTHERS PUBLISHERS
MCMVIII

Copyright, 1908, by Harper & Brothers.

 ———
All rights reserved.
Published April, 1908.
 Contents

Book I Youth and the Silver Swan

Book II “How a Man May Find His Soul Again”
Book III “The Oak of Mivoie”

Transcriber’s Notes can be found at the end of this eBook.

TO
MY DEAR FRIEND
JULIA ORD

Bertrand of Brittany
 BOOK I
YOUTH AND THE SILVER SWAN
 I
It had always been said in the Breton lands that Sieur Robert du
Guesclin was a brave man, save in the presence of that noble lady,
Jeanne de Malemains, his wife.
Now Dame Jeanne was a handsome, black-browed woman with a
resolute mouth and a full, white chin. The Norman apple-trees had
lost their bloom, so sang the romancers, when Gleaquim by the sea
had stolen her as the sunlight from Duke Rollo’s lands. The Lady
Jeanne had brought no great dowry to her husband, save only her
smooth and confident beauty, and the perilous blessings of a
splendid pride. She had borne Sieur Robert children, fed them at her
own breast as babes, and whipped them with the stern sense of her
responsibility heavy in her hand. It was well in those days for a wife
to watch strong sons growing into manhood about her husband’s
table. One fist the more, and the surer was the mother’s honor when
enemies might speak with her good man at his gate.
Proud, lovely, and masterful, the Lady Jeanne had looked to see
her majesty repeated in her children. It had been but the legitimate
and expectant vanity of a mother to dower her first-born with all the
grace and beauty of a Roland. Poor dame, the thing had seemed as
ugly as sin when it first kicked and squalled in her embroidered
apron; bristling hair, a pug of a nose, crooked limbs, skin like a pig’s!
Every passing month had brought the brat into more obvious
disfavor. Its temper appeared as ugly as its body. It would bite and
yell with a verve and fierceness that made the nurse vow it was an
elf’s child, a changeling, or some such monstrosity. The Lady Jeanne
had grieved, prayed to the saints, and yet been at a loss to discover
why her motherhood should have been shamed by such a child.
Years passed, and still mother and son were no better accorded.
Jeanne, proud lady, had no joy or pleasure in her eldest child. His
ugliness increased: he was wild as a passage hawk, rebellious,
passionate, yet very sullen. The younger children went in terror of
him; the servants felt his fists and teeth; he fought with the village
lads, and came home bloody and most whole-heartedly unclean.
Sieur Robert might break many a good ash stick over Master
Bertrand’s body. His mother might storm, scold, clout, and zealously
declaim; the ugly whelp defied her and her gentlewomen. He had no
more respect for a lady than for Huon, the miller, whose apples he
stole, and whose son he tumbled into the mill-pool.
Poor Jeanne du Guesclin! The fault was with her pride—and with
no other virtue. She could not love the child, and nature, as though
in just revenge, mocked with the clumsiness of the son the vanity of
the mother. Young Bertrand was starved of all affection. His very
viciousness was but a protest against the indifference of those who
made him. Cuffed, chided, sneered at, he grew up like a dwarfed
and misshapen oak that has been lopped unwisely by the forester’s
bill. He was slighted and ignored for Olivier, the second son, whose
prettiness atoned with Jeanne for her first-born’s snub nose and ugly
body. It was Olivier whom the mother loved, the sleek and clean-
faced Jacob ousting poor Esau into the cold. Often Bertrand rebelled.
The good child would come snivelling to his mother with a wet nose
and a swollen cheek.
“See what Bertrand has done to me!”
The sneak! And Bertrand—well, he would be cuffed into the dark
cellar under the solar floor, and be left there with bread and water to
meditate on the beauty of motherly affection. And yet within a week,
perhaps, sweet Olivier would boast another bloody nose, and the
whole process be repeated.
Such was Bertrand’s upbringing, with all the fierce instincts
pampered in his heart, all the gentler impulses chilled and stunted
for lack of love. Bertrand’s figure was a slur on the Du Guesclin
shield. He had no manners and no graces, and loved to herd with
the peasant lads, and wrestle with ploughmen rather than listen to
the romances of chivalry at his mother’s knee. While Olivier had the
adventures of Sir Ipomedon by heart, and knew the lays of Marie de
France, his brother Bertrand robbed orchards and used his fists,
growing into a brown-faced, crab-legged young rascal who looked
more like a peasant’s child than the son of Jeanne the Proud of
Normandy.

The May-trees were white about Motte Broon in the year of our
Lord 1338, the meadows were covered with tissue of gold. Dame
Jeanne walked in her garden, dressed in a gown of yellow sarcenet,
her black hair bundled into a silver net. To the west of the little lawn
stood a yew-hedge, over which the sun was sinking, to plunge into
the mystery of the darkening woods. Several tall aspens glittered in
the evening light. The smoke rose straight from the octagonal
chimneys of the château.
Dame du Guesclin walked on the grass round the stone vivarium
with its darting fish, Sieur Robert strolling beside her, stroking his
amiable and brown-bearded chin, and listening to her as to an oracle
as she talked. The Lady Jeanne was in one of her masterful moods;
moreover, she was tired and out of temper, and in no mind to be
reasoned with, even though the tongue of an angel had pleaded the
cause of the ugly son.
“Robert, I tell you Bertrand must not go to Rennes. We can leave
him with Father Isidore, and Olivier will do us honor. I have been
stitching some gold stuff on the lad’s best côte-hardie, and sewing
some of my own jewels into his cap. Olivier will make a show among
the bachelors.”
Du Guesclin’s sleepy eyes wandered for a moment over his wife’s
face.
“So you would not have us take Bertrand, wife?” he repeated.
The lady pouted out her lower lip.
“Think of it, Robert—think of Bertrand in such company! Good
Heavens! Why, the lad is only fit to take his meals in an ale-house;
the lout would disgrace us, and set the whole town laughing.
Besides, he has no clothes; his best surcoat was slit down the back
last Sunday by a Picard fellow whom he threw into the church ditch.
I’ll not have the young fool shaming us before all the gentlemen of
Brittany.”
 “The lad may take it to heart,” said the husband, troubled with
recollections of his own youth.
“Nonsense!” returned Dame Jeanne, “Bertrand has no pride; his
tastes are low, and he is without ambition. Often I think that the boy
is mad. Moreover, Robert, there is no horse. Olivier must have the
gray, and there is only Yellow Thomas, with his broken knees and
stumpy tail. He is good enough for Bertrand as things go, but
imagine the oaf riding into Rennes beside you on Yellow Thomas,
and his surcoat split all up the back!”
Du Guesclin could not forbear a chuckle at the picture painted by
his wife.
“Then we will leave Bertrand to Dom Isidore,” he said.
“Ah, Robert, you are a man of sense! I do not want to be cruel to
the lad, but he has no figure for gay routs, he is no courtier—only a
clumsy fool. I have no wish to be shamed by one of my own
children. Olivier is quick and debonair; that lad will do us credit.”
The Lady Jeanne had hardly emphasized this last piece of
treachery to her first-born by laying her large white hand on her
husband’s shoulder, when there was a fierce bustling among the
yew-trees, as though some young ram had been caught by the
horns and was struggling to break through. The green boughs were
burst asunder. A pair of hands and a black pate came burrowing
through the yew-hedge into the light.
“Bertrand!”
And an ugly vagabond the lad looked, with his huge hollow chest,
arms long and powerful as an ape’s, bowed legs, and head sunk
between his shoulders. His green eyes were glittering under their
heavy brows, his mouth working in a way that was not calculated to
make him seem more serene and beautiful.
“Bertrand!”
The Lady Jeanne’s voice was hard and imperious. It is never
flattery to the inner self to be overheard plotting a mean act, and
the coincidence was not soothing to the lady’s temper. She was not
the woman, however, to be startled out of her judicial calm. In such
a case it was better to brandish the whip than to hold out the hand.
“Bertrand, you have been eavesdropping!”
 The lad had approached them over the grass, walking with that
bow-legged but springy action peculiar to some men of great
physical strength. His forehead was all knotted up in wrinkles, and
he was breathing heavily, as though under the influence of strong
emotion.
“Mother, I’ll kill Olivier! I’ll break his bones—”
“Bertrand, stand back! How dare you threaten?”
“Curse Olivier! I tell you I will go to Rennes.”
“Rennes!”
“Yes; why should I not go? I am your son, mother. By Heavens!
when will you treat me as you treat Olivier?” He gulped down some
great sob of feeling that was in his throat, and turned to his father
with moist eyes. “Sire, say that I may go to Rennes.”
Du Guesclin winced, fidgeted, and glanced at his wife.
“What shall I say to the lad, Jeanne?” he asked.
“Leave him to me,” she said, quietly. “I will show the fool the
honest truth.”
Sieur Robert surrendered to his wife’s discretion, and, retreating
towards the château, settled himself on a bench under an almond-
tree that was still in bloom. Jeanne stood watching her husband over
her shoulder. Presently she turned again to Bertrand with that regal
and half-contemptuous air he had known so well of old. Jeanne
stared at the lad in silence for some moments, the angles of her
mouth twitching, her eyes cold and without pity.
“Bertrand!”
Her tones were sharp, hard, and incisive. The lad nodded,
slouching his shoulders, and looking surly and ill at ease.
“Bertrand, can you serve or carve at table?”
“No.”
“Can you sing or play the lute, dance, or make courtly
speeches?”
“No.”
“Can you amuse a great lady?”
“No.”
“Where are your fine clothes, your armor, and your horse?”
“Mother, you know I have none.”
 Dame Jeanne’s eyes were fixed with a malicious glitter upon his
face. She knew how to crush the lad, to sting into him the realization
of his unfitness for the polite pageantry of life.
“Listen to me, Bertrand: you will never make a gentleman.”
He winced, and looked at his mother sulkily under his heavy
brows.
“How can such as you mix with the lords and ladies of France
and Brittany—you, who herd with ploughboys and scuffle with
scullions? Bah, you fool! they would only laugh at you at Rennes,
and take you for a groom who had sneaked in from the stables! Go
to Rennes, indeed—to Jeanne de Penthièvre’s wedding! Who ever
heard such nonsense! Where are your manners, Messire Bertrand?
Where are your fine clothes, your airs and graces? Where are you
going to find a horse? No, no; the honor and fortune of the family
must be remembered.”
Bertrand stood gnawing his finger nails in humiliation. He knew
that he was ugly, rough, and violent, and he half suspected that his
mother’s words were true. And yet what chance had she ever given
him to show his mettle? He had been the spurned dog since he
could remember.
“Well, Bertrand, what have you to say to me?”
“Nothing,” he growled, hanging his head and staring at the grass.
Suddenly, as though to end the lad’s torture, there came the cry
of a trumpet from the road across the meadows. Dame Jeanne
heard it, and turned her head. Sieur Robert had risen from the seat,
and climbed the stairway leading from the garden to the solar. He
looked out over the palisading above the moat towards the
meadows, sheeted in the sunlight like cloth of gold.
“The banner of the De Bellières!” he cried, beckoning to his wife.
“Come, Jeanne, leave the lad; we must be ready to make them
welcome.”
 II
Bertrand did not follow his mother, but stood watching her as she
crossed the garden, the evening sunlight shining on her gown of
yellow sarcenet. He saw her halt for a moment, and glance up at the
window of the solar that overlooked the garden. Olivier was leaning
out over the sill, waving his cap, and watching the Vicomte de
Bellière’s company as it wound along the road through the
meadows. Bertrand knew that Dame Jeanne was smiling at Olivier—
smiling at him in that fond, proud way that Bertrand had never
known.
He slunk away behind the trees, for Olivier was calling to him
from the window.
“Hi! Bertrand, old bandy-legs! What will you do for a new
surcoat? Here are the De Bellières on their way to Rennes! You had
better hide among the grooms when you come in to supper!”
The younger lad had a spiteful tongue, and the wit to realize that
he held his brother at a disadvantage. Of old Bertrand would have
broken out into one of his tempests, but he had learned the
uselessness of avenging himself upon Olivier.
He retreated behind the yew-trees, and, going to a palisading
that topped the moat, stood watching the Vicomte de Bellière’s
company flashing towards the château. Poor Bertrand, he had set
his heart on going to Rennes! Had not his old aunt Ursula, at
Rennes, persuaded her husband to give the lad a spear and a coat
of mail! By stealth Bertrand had built himself a rough quintain in a
glade deep in the woods about the castle. Many a morning before
the sun was up he had sneaked into the stable, harnessed his
father’s horse, and ridden out with spear and shield to tilt at the
quintain in the woods. Old Hoel, the gate-keeper, who was fond of
the lad, had winked at the deception. And then as the sun came
glittering over the woods, and the grass gleamed with the quivering
dew, Bertrand would thunder to and fro on Sieur Robert’s horse,
grinding his teeth, and setting the quintain beam flying round like a
weather-cock in a squall.
Great bitterness overcame Bertrand’s heart that evening. He
knew that he was of no great worth in the eyes of his father and
Dame Jeanne, but he had never fully grasped the truth that they
were ashamed of him because he was their son. Olivier was all that
a vain mother might desire—pert, pretty, straight in the limbs, with a
fleece of tawny hair shining about his handsome face. Bertrand
supposed that it was an evil thing to be ugly, to be the possessor of
a snub nose and a pair of bandy legs.
And yet he could have loved his mother had she been only just to
him. What had driven him to herding and fighting with the peasant
lads? The Lady Jeanne’s indifference,—nay her too candid
displeasure—at his presence in the house. What had made him
rough and sullen, shaggy and obstinate, violent in his moods and
uncertain in his temper? His mother’s sneers, her haughty
preference for Olivier—even the way she shamed him before the
servants. Bertrand believed that they wished him dead—dead, that
Olivier might sit as their first-born at their table.
All these bitter thoughts sped through Bertrand’s heart as he
leaned against the palisading, and watched the line of horses
nearing his father’s house across the meadows. There was the
Vicomte’s banner—a blue chevron on a silver ground—flapping
against the evening sky. Stephen de Bellière rode a great gray horse
all trapped in azure with silver bosses on the harness. Beside him,
like a slim pinnacle towered over by the copper-clad steeple, for the
Vicomte’s armor and jupon were all of rusty gold, rode a little girl
mounted on a black palfrey, her brown hair gathered into a silver
caul. On the other side, a boy, young Robin Raguenel, cantered to
and fro on a red jennet. Behind the Vicomte came two esquires
carrying his spear and shield, and farther still some half a dozen
armed servants, with a rough baggage-wagon lumbering behind two
black horses. The little girl had a goshawk upon her wrist, and two
dogs gambolled about her palfrey’s legs.
 Bertrand watched them, leaning his black chin upon the wood-
work, and waxing envious at heart over a pomp and glamour that he
could not share. The Vicomte’s horse-boys were better clad than he.
And as for Stephen Raguenel, he seemed to Bertrand, at a distance,
a very tower of splendor. To boast such a horse, such arms, and
such a banner! The Vicomte must be a happy man. So thought
Bertrand, as he gnawed his fingers and beat his knee against the
fencing.
Robert du Guesclin and the Lady Jeanne had come out from the
gate-house, and were standing at the head of the bridge to welcome
their guests. Dame du Guesclin had her arm over Olivier’s shoulder.
They were laughing and talking together, and the sight of it made
poor Bertrand wince. He turned away with an angry growl, and,
sitting down on a bench under an apple-tree, leaned his head
against the trunk, stared at the sky, and whistled.
Half an hour passed, and the Vicomte and his two children had
been taken into the hall to sup. Bertrand could hear the grooms and
servants chattering in the stable-yard as they rubbed down the
horses. From the hall came the sound of some one playing on the
cithern. Bertrand could see the window to the west of the dais from
where he sat, alive with light as with the flare of many tapers. He
heard Olivier’s shrill laugh thrill out above the cithern-playing and
the rough voices in the yard. They were very merry over their
supper; nor did they miss him. No. He was nothing in his father’s
house.
Dusk was falling, though a rare afterglow crimsoned even the
purple east. The yews and apple-trees in the garden were black as
jet, and the bats darted athwart the golden west. The long grass
was wet with dew. Bertrand shivered, stretched himself, sat up, and
listened. He was hungry, but then he had no stomach for the great
hall where no one wished for him, and where the very guests might
take him for a servant. He would sneak round to the pantry and get
some bread and a mug of ale from the butler’s hatch.
There was a sudden rustling of the grass under the tree, a low
whimpering, and a wet nose thrust itself against Bertrand’s hand.
Then a pair of paws hooked themselves upon his knee, and a cold
snout made a loving dab at the lad’s mouth.
“Why, Jake—old dame!”
The dog whimpered and shot out her tongue towards Bertrand’s
cheek.
“Jake, old lady, they have all forgotten me, save you.”
He fondled the dog, his great brown hands pulling her ears with
a tenderness that seemed strange in one so strong and ugly. He laid
his cheek against Jake’s head, and let her lick his neck and ear, for it
was sweet to be remembered—even by a dog.
“Well, old lady, have you had your supper? What, not a bone! By
St. Ives! we will go in, in spite of them, and sup together by the
fire.”
He rose, and the dog sprang away as though welcoming the
decision, and played round him, barking, as he crossed the garden
towards the court.
When Bertrand entered the hall with Dame Jake at his heels the
grooms and underlings were taking their places at the trestled
tables. The walls were bare, save behind the dais, where crimson
hangings hung like a mimic sunset under the deep shadows of the
roof. The fire was not built on a hearth in the centre of the floor, but
under a great hooded chimney in the wall midway between the high
table and the screens. There was no napery on the lower boards,
and the servant folk used thick slices of brown bread in place of
platters.
Bertrand cast a quick and jealous glance at the high table, and
then went and sat himself on a stool before the fire. The logs were
burning brightly on the irons, licking a great black pot that hung
from the jack. Neither Dame Jeanne nor her husband had seen
Bertrand enter. They were very gay and merry on the dais, the
Vicomte between Sieur Robert and his wife, Olivier feeding little
Robin with comfits and sugar-plums, and Tiphaïne, the child, sitting
silent beside Dame Jeanne, with her eyes wandering about the hall.
Bertrand felt some one nudge his shoulder. It was old Hoel, the
gate-keeper, his red face shining in the firelight under a fringe of
curly hair. He held a tankard in one hand and half a chicken and a
hunch of bread on a hollywood platter in the other.
“You have not supped, messire,” he said.
Bertrand glanced at the old man over his shoulder.
“Good man, Hoel, I’ll take what you are carrying. Bring me a
mutton-bone for Jake.”
Bertrand pulled out his knife, set the tankard down amid the
rushes, and, ignoring the inquisitive glances of the Vicomte’s
servants, fell to on the bread and chicken. There was much
gossiping and gesturing at the servants’ table. A man-at-arms with a
pointed black beard and a red scar across his forehead was asking
Sieur Robert’s falconer who the ugly oaf on the stool might be.
Bertrand caught the words and the insolent cocking of the soldier’s
eye as he looked him over and then grimaced expressively.
“ ’Sh, friend, the devil’s in the lad.”
“True, friend, true,” quoth Bertrand, coolly throwing his platter at
the soldier’s head.
It was the first incident that had called the attention of those at
the high table to the lad seated by the fire. To Bertrand the richly
dressed figures loomed big and scornful before the crimson
hangings, all starred and slashed with gold. He saw the Vicomte
stare at him and then turn to Sieur Robert with a courtly little
gesture of the hand. Dame Jeanne was sitting stark and stiff as any
Egyptian goddess. Bertrand saw her flush as the Vicomte questioned
her husband, flush with shame that the lad on the stool should be
discovered for her son. Bertrand blushed, too, but with more anger
than contrition. He heard Olivier’s shrill, squealing laugh as he
tossed Robin an apple and bade him throw it at “the lout upon the
stool.” Every eye in the hall seemed fixed for the moment upon
Bertrand. He knew that the “mean” folk were mocking at him, and
that the great ones on the dais—even his own mother—regarded
him with a feeling more insolent than pity.
Dame Jake, oblivious to the tableau, sat up upon her hind-legs
and begged. She waved her fore-paws in the air, almost as though
to recall Bertrand to the fact that he had one friend in his father’s
hall. Bertrand took a piece of bread, rubbed it on a chicken-bone,
and tossed it to her with a growl of approval. Jake swallowed the
morsel and then sat with her muzzle on her master’s knee, her eyes
fixed upon his face.
At the high table the child with the brown hair coiled up in a
silken caul had laid her hand on the Lady Jeanne’s arm.
“Madame, who is that?”
Dame du Guesclin fidgeted with the kerchief pouch at her girdle
and frowned.
“Who, child, and where?”
“The man on the stool, with the dog.”
“That is Bertrand, my sweeting.”
“And who is Bertrand?”
“Why, child, my son.”
Tiphaïne’s great eyes were turned full upon the elder woman’s
face. Lady Jeanne was red despite her pride, and ill at ease under
the child’s pestering.
“Why does he not sit with us on the dais?”
“Why? Well, little one”—and the Lady Jeanne laughed—“Bertrand
is a strange lad. He is not like Olivier or your brother Robin.”
Tiphaïne had been scanning the handsome face above her, with
its curling lips and its contracted brows. There was something that
puzzled her about the Lady Jeanne. Why had she turned so red, why
did her eyes look angry, and why did she tap with her foot upon the
floor?
“Madame, may I ask Bertrand to come up hither?”
“No, child, no. See—here is the comfit-dish, or would you like a
red apple? Olivier, Olivier, bring me the bowl of silver. Child, what are
you at?”
For Tiphaïne had risen and had slipped round the table end
before Jeanne du Guesclin could lay her hand upon her arm. She
sprang down lightly from the dais and moved over the rush-strewn
floor and under the beamed and shadowy roof to where Bertrand sat
sullen and alone before the fire.
Bertrand was sitting staring at the flames and thinking of the
sights that would be seen at Rennes, when he was startled by the
gliding of the child’s figure into the half-circle of light. He looked up,
frowning, to find Tiphaïne’s eyes fixed on his with a questioning
steadfastness that was not embarrassing. For several seconds
Bertrand and the child looked thus at each other, while Dame Jake
lifted her head from her master’s knee and held up a paw to
Tiphaïne as though welcoming a friend.
The dog’s quaintness proved irresistible. Tiphaïne was down on
her knees amid the rushes, hugging Dame Jake and laughing up at
Bertrand with her eyes aglow.
“Ah—Bertrand—the dear dog! What is its name?”
“Jake—Dame Jake.”
Bertrand was astonished, and his face betrayed the feeling. He
was looking at Tiphaïne as though she were like to nothing he had
seen on earth before. The child had one of those sleek brown skins,
smooth as a lily petal, with the color shining through it like light
shining through rose silk. Her great eyes were of a beautiful amber,
her hair a fine bronze shot through with gold. There would have
been the slightest suggestion of impudence about the long mouth
and piquant chin had not the gentleness of the child’s eyes and
forehead mastered the impression. She was clad in a côte-hardie of
apple-green samite, shaded with gold and embroidered with gold-
work on the sleeves. Her tunic was of sky blue, her shoes of green
leather, her girdle of silver cords bound together with rings of divers-
colored silks.
Bertrand looked at her as though he had not overcome the
surprise with which her coming filled him. Perhaps she was cold and
had left the high table to warm herself at the fire. In the village
Bertrand had won for himself something of the character of an ogre,
and the children would run from him and hide in the hovels.
Tiphaïne was still fondling the dog and looking at Bertrand. The
lad jumped up suddenly and offered her his stool.
“Take it,” he said, gruffly, thrusting it towards her.
She shook her head, however, smiling at him, her hand playing
with Dame Jake’s ears. Bertrand, flushing, sat down again and
stared at her.
“As you will,” he said. “You like the dog, eh? Yes, I have had Jake
since she was a puppy.”
 There was a puzzled look in Tiphaïne’s eyes. She was wondering
why the Lady Jeanne had said that Bertrand was not like Olivier or
her brother Robin. He was ugly, and his clothes were shabby, and
yet she discovered something in his face that pleased her. His very
loneliness touched some sensitive note in the child’s soul, for she
was one of those rare creatures who are not eaten up with
selfishness at seven.
“Why did you not sup with us?” she asked, suddenly.
Bertrand stared at her, and felt that there was no evading those
brown eyes.
“Because I was not wanted,” he answered.
This time it was Tiphaïne who gave a little frown.
“But you are Sieur Robert’s son!”
Bertrand winced, and then smiled with a twisting of the features
that betrayed the truth.
“I am no use to them,” he said.
“No use?”
“Look at me. Did you ever see such an ugly wretch? I should
frighten you all at the high table—I suppose. And they tell me I have
no manners. No. They would rather see me hidden among the
servants.”
Tiphaïne looked shocked. It was plain even to her childish
wisdom that she had lighted on some passionate distress, the depth
and fierceness of which were strange to one who had never lacked
for love.
“Are you older than Olivier?” she asked.
Bertrand nodded.
“Then why does he take your place?”
“Because he has straight legs and a pretty face; because they
love him; because I am such a clumsy beast,” and he shut his mouth
with a rebellious growl.
Tiphaïne drew herself nearer to him amid the rushes. She was
still fondling Dame Jake’s ears.
“I do not think that you are clumsy, Bertrand,” she said.
“Ah—!”
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