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AACN
Core Curriculum
/orProgressive
and Critical Care
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TONJA M. HARTJES, Editor

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2019v1.0
AACN
Core Curriculum
for Progressive
and Critical Care
Nursing
TONJA M. HARTJES, Editor
DNP, APRN, CNS, CCRN, CNEcl, FAANP
Owner, Nurse Practitioner and Consultant
Nursing Department
Coastal Consultants and Education LLC
St. Augustine Beach, Florida

Edition
8
Elsevier
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AACN CORE CURRICULUM FOR PROGRESSIVE  ISBN: 978-0-323-77808-4

AND CRITICAL CARE NURSING, EIGHTH EDITION

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

iii
iv Contributors

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

Anesthesiology, Critical Care Medicine
University of Kentucky
Lexington, Kentucky
Chapter 8: Hematologic and Immunologic Systems

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

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

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

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

Patricia Radovich, PhD, CNS, FCCM

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

Angie Atwood, PhD, RN

Assistant Professor of Nursing
Campbellsville University
Campbellsville, Kentucky

Michele Beatty Bachmann, MSN, RN

Instructor
Department of Primary Care
Southern Illinois University – Edwardsville
Edwardsville, Illinois

Beverly L. Banks, BSN, MSN, RN

Senior Full-Time Faculty
Nursing
Alpena Community College
Alpena, Michigan

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

Director of Professional Development and Magnet Program
Lutheran Medical Center
Wheat Ridge, Colorado

Collin Bowman-Woodall, MSN, RN

Assistant Professor
Samuel Merritt University, School of Nursing
San Mateo, California

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

Acute Care Nurse Practitioner
Department of Critical Care Medicine and Surgery
University of Florida
Gainesville, Florida

vii
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viii Reviewers

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

Nurse Scientist
University of California – San Diego Health Sciences;
Scientist
Department of Psychiatry
University of California – San Diego, School of Medicine
La Jolla, California;
Associate Editor
Journal of Nursing Management

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

Hospital Accreditation Program Surveyor
The Joint Commission;
Adjunct Faculty, Nursing
Queens University
Charlotte, North Carolina

Christina Flint, MSN, MBA, RN

Assistant Professor
University of Indianapolis, School of Nursing
Indianapolis, Indiana

Matthew J. Fox, MSN, RN-BC

Assistant Professor
Nursing
Ohio University
Zanesville, Ohio

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

Registered Nurse
Medical and Surgical Intensive Care Units
Orange Regional Medical Center
Middletown, New York;
Montefiore Medical Center
Bronx, New York

Kelly A. Gaiolini, RN
Staff Nurse, Neuro/Surgical Intensive Care Unit
Lawnwood Regional Medical Center
Fort Pierce, Florida

Charles R. Gold, BSN, RN, CCRN

Registered Nurse
Neurosurgical Intensive Care Unit
Atrium Health’s Carolinas Medical Center
Charlotte, North Carolina
 Reviewers ix

Ami Grek, DNP, APRN, ACNP-BC

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

Christopher Guelbert, DNP, RN, CCRN, CNML

Assistant Professor
Nursing
Barnes Jewish College
St. Louis, Missouri

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

Associate Professor
Ferris State University
Big Rapids, Michigan

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

Facility Director, Advanced Practice Providers
Intensivist Nurse Practitioner
Intensive Care Consortium
Gainesville, Florida

Jillian Hamel, MS, RN, ACNP-BC

Acute Care Nurse Practitioner
Emergency Department Observation Unit
Providence Regional Medical Center
Everett, Washington

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

Dean and Professor
University of Louisville, School of Nursing
Louisville, Kentucky

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

Chief Advanced Practice Clinician
MedStar Montgomery Medical Center
Olney, Maryland

Cheryl Holsworth, MSA, RN, CBN, CMSRN

Senior Specialist for Bariatric Surgery
Sharp Memorial Hospital
San Diego, California
x Reviewers

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

Assistant Professor
Lourdes University, College of Nursing
Sylvania, Ohio

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

Associate Professor
Liberty University, School of Nursing
Lynchburg, Virgina

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

Clinical Nurse Specialist and Educator
Cardiac ICU
University of Colorado Hospital
CHealth
Aurora, Colorado

Marianna LeCron Presley, MSN, RN, CCRN

Critical Care Nurse
Medical Intensive Care
Atrium Health Pineville
Charlotte, North Carolina

KellyAnne Lee, MSN, MBA, RN, CCRN

Healthcare Consultant
Coasta Consulting Group, LLC
Mount Pleasant, South Carolina

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

Clinical Nurse Educator
Surgical/Medical Intensive Care Units
North Florida South Georgia Veterans Health System
Gainesville, Florida

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

Family Nurse Practitioner
Emergency Department
Memorial Hospital
Jacksonville, Florida

Karen A. Matos, MSN, RN, CCRN

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

Paige McCraney, DNP, APRN

Adult Health Nurse Practitioner
Assistant Professor
University of North Georgia Department of Nursing
Dahlonega, Georgia
 Reviewers xi

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

Associate Professor Nursing
Kent State University – Tuscarawas
New Philadelphia, Ohio

Katina M. Meyer, BSN, RN

Registered Nurse
Medical Intensive Care Unit
Stormont Vail Health
Topeka, Kansas

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

Nurse Practitioner
Flourish Health Network
Gainesville, Florida

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

Professor of Neurology & Neurotherapeutics
Professor of Neurosurgery
Distinguished Teaching Professor
University of Texas Southwestern Medical Center
Dallas, Texas

Sarah Peacock, DNP, APRN, ACNP-BC

Lead Advanced Provider
Department of Critical Care Medicine
Mayo Clinic
Jacksonville, Florida

Deidra Pennington, MSN, RN

Assistant Professor
Nursing
Jefferson College of Health Sciences
Roanoke, Virginia

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

Director, Graduate Nursing Studies
JoAnne Gay Dishman School of Nursing
Lamar University
Beaumont, Texas

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

Nurse Practitioner, Department of Critical Care
Mayo Clinic
Jacksonville, Florida
xii Reviewers

Janet Czermak Russell, DNP, RN, APN-BC

Associate Professor of Nursing
Nursing/Biology
Essex County College
Newark, New Jersey

Peter D. Smith, BA, MSN, RN

Clinical Education Specialist
Nursing Education
Kindred Healthcare
St. Louis, Missouri

Diane Fuller Switzer, DNP, ARNP, FNP-BC, ENP-BC, ENP-C, CCRN, CEN, FAEN
Assistant Clinical Professor
Seattle University, College of Nursing
Seattle, Washington

Ashley N. Thompson, DNP, AGACNP-BC

Acute Care Nurse Practitioner, Assistant Professor
UF Health/University of Florida
Gainesville, Florida
Preface
Since the early 1970s, the American Association of Critical-Care Nurses (AACN) and its
AACN Core Curriculum have stood at the forefront of the continuing evolution of criti-
cal care nursing to better meet the highly specialized needs of the patients and families
they serve. The AACN Core Curriculum has now undergone eight editions, during which
time it has maintained its reputation as the source of all things critical care. Among sev-
eral steps we took to help prepare for this edition, AACN and I issued a reader survey and
gathered together a cross-section of expert clinicians for a focus group during the organi-
zation’s National Teaching Institute & Critical Care Exposition in 2019. Our goal was to
gather information to ensure that this newest edition kept pace with the expanding role
of nurses in the critical care profession. Participants confirmed the many ways the AACN
Core Curriculum is used: as a clinical reference in caring for progressive and critical care
patients, as a resource for CCRN certification exam preparation, for the creation of critical
care courses and curricula, as a cornerstone for new nurse orientation, and in the develop-
ment of competency content. Several nurses with whom we spoke stated that the AACN
Core Curriculum was their “critical care bible,” affirming that after all these years it is still an
actively sought-after resource within critical care nursing practice.
As we listened to readers and collected information from multiple sources, we confirmed
that the purpose of the AACN Core Curriculum remains, as it always has been, to articulate
the knowledge base that underlies progressive and critical care nursing practice. Each edi-
tion of this work attempts to redefine that knowledge base for nurses who practice in this
ever-expanding specialty area.
The eighth edition has been retitled AACN Core Curriculum for Progressive and Critical
Care Nursing. Critical care practice and nursing have evolved over the past decade. Acutely
ill patients are treated in many units of the hospital, from the Medical-Surgical departments
to progressive and intermediate care units and elsewhere. Patients requiring critical care
also are found outside the intensive care unit. Specialty nursing units have been created to
meet these evolving health care needs; critical care nurses and patients are found in car-
diac catheterization labs, emergency departments, and tele-ICUs. Sometimes they are even
found at home awaiting heart transplant with inotropic medications and a left ventricular
assist device. Changing the title of the text as we have done brings the resource more in
line with the varied settings in which we find critically ill patients, and it signals to readers
outside the traditional ICU that they are included in our base of readers.
Several similarities still exist between the seventh and eighth editions. The current edi-
tion continues to use the CCRN Examination blueprint and task statements as a starting
point for determining relevant content and its apportionment throughout the book. We
continue with the embellished outline format, and body systems are again used to divide
the major content areas into chapters. Subsections related to physiologic anatomy, patho-
physiology, and patient assessment; generalized patient care; and unique characteristics of
specific disorders also have been retained.
Readers can still find the AACN Synergy Model for Patient Care woven throughout this
edition. When it was developed in the late 1990s, the Synergy Model became the conceptual
framework for certified practice in critical care and has since been widely incorporated
across the discipline. Chapter 1 describes the model in detail, and each chapter includes in
the assessment section a reminder of the model’s prevalence. A key premise of the Synergy
Model is that patient characteristics drive the competencies that nurses need in order to
xiii
xiv Preface

provide holistic, healing care that achieves optimal patient outcomes. A knowledge base of
critical care nursing underlies clinical practice and reflects a foundational requirement for
the development of these nursing competencies.
AACN’s Competency Based Assessment (CBA) framework was incorporated as “lev-
eling” guidance using the Synergy Model for Patient Care and the expanded outline format
and embellishment items within the text. The terms novice, advanced beginner, proficient,
and expert were used to operationalize the nurse competency and leveling of content within
the AACN Core Curriculum.
The Novice or Advanced Beginner is encouraged to focus on the following content for
foundational knowledge:
Section 1: System Wide Elements
• Anatomy and Physiology Review
• Assessment
• Patient Care
• The new “Key Concept” highlight boxes have been expanded throughout the text,
and replace “Key Points” from the seventh edition
Proficient or Expert learners are encouraged to focus on the following content for
expert knowledge:
Section 2: Specific Patient Health Problems
• Health Problems
• Pathophysiology, Etiology, Signs and Symptoms, Diagnostic Findings, Management
of Patient Care, Complications, End Organ Diseases
• The new “Expert Tip” highlight boxes have been expanded throughout the text, and
replace the “Clinical Pearls” from the seventh edition
To keep pace with the expanding role of progressive and critical care nursing practice
and the evolving health care arena, the following items have been added or updated:
• Reorganization of content into four sections:
Part I: Foundations of Progressive and Critical Care Nursing
Part II: Critical Care of Patients with Issues Affecting Specific Body Systems
Part III: Critical Care of Patients with Multisystem Issues
Part IV: Critical Care of Patients with Special Needs
• Removal of all subchapters
• A new Perioperative Care chapter
• The text features improved navigation, format, and usability with a new, full-color, user-
friendly interior design that uses high-contrast text colors and a larger font.
• A Crosswalk was created at the beginning of each chapter that interfaces or maps foun-
dational nursing content within key educational and clinical documents including the
following:
• Quality and Safety in Nursing Education (QSEN) competencies
• National Patient Safety Goals
• American Nurses Association (ANA) Standards for Professional Nursing Practice
• American Association of Critical-Care Nurses (AACN) Standards for Progressive and
Critical Care Nursing Practice
• American Association of Critical-Care Nurses Healthy Work Environments
• Progressive and Critical Care Nursing Certification
• All chapters, tables, figures, boxes, and terminology are based on the most recently pub-
lished AACN/ANA Scope of Practice and Standards of Care.
• QSEN content has been incorporated within chapters of the text.
• The newest sepsis guidelines content has been added to Chapter 10.
 Preface xv

• All references complement and reinforce current AACN and critical care standards and
guidelines of care.
• References and bibliographies for all chapters are now available online on the Evolve site
at http://evolve.elsevier.com/AACN/corecurriculum/.
• Each chapter was carefully reviewed by AACN clinical practice specialists as well as by
a nurse in current critical care practice. A clinical pharmacist also reviewed all medica-
tions for correct indication and dosages.
The contributors, reviewers, AACN clinical practice specialists, and I have worked tire-
lessly and made every attempt to provide the most current and relevant knowledge base
of information related to progressive and critical care nursing. I welcome your comments
about this edition and your suggestions for future editions of the AACN Core Curriculum.

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

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

xvii
 Visit https://ebookmass.com
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Contents
PART I Foundations of Progressive and Critical Care Nursing
Chapter 1 Professional Caring and Ethical Practice1
Anna Dermenchyan, MSN, RN, CCRN-K, CPHQ
American Association of Critical-Care Nurses Mission, Vision, and Values
(AACN, 2020 a,b,c)
1
Mission1
Vision2
Values2

Synergy of Caring2
Key Responsibilities of Registered Nurses (American Nurses Association [ANA], 2020) 2
What Acute and Critical Care Nurses Do (AACN, 2019) 2
The Environment of Progressive and Critical Care Nurses (AACN, 2019) 2
The AACN Synergy Model for Patient Care 5

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

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

Healthy Work Environment Standards (AACN, 2016)17

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

Ethical Clinical Practice24

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

Chapter 2 Psychosocial Aspects of Critical Care38

Deborah Chapa, PhD, ACNP-BC, FAANP, ACHPN; Bimbola Fola Akintade, PhD, MBA, MHA, ACNP-BC, NEA-BC, FAANP
Systemwide Elements38
Review of Psychosocial Concepts 38
Assessment 43
xix
xx Contents

Pain, Agitation, Delirium, Immobility and Sleep Disruption (PADIS) (Devlin et al., 2018) 44
Sleep Deprivation 46
ASD and PTSD 46
Delirium (Acute Confusional State) 48
Powerlessness 50
Anxiety 51
Depression 53
Substance Misuse, Dependence, and Withdrawal 55
Aggression and Violence 57
Suicide 59
Dying Process and Death 61

PART II  ritical Care of Patients with Issues Affecting Specific Body

C
Systems
Chapter 3 Pulmonary System 63
Daniel N. Storzer, DNP, ACNPC, ACNP-BC, CNRN, CCRN, CCEMT-P, FCCP, FCCM
Systemwide Elements63
Anatomy and Physiology Review 63
Assessment 85
Diagnostic Studies  105
Patient Care 109

Specific Patient Health Problems 136

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

Chapter 4 Cardiovascular System 176

Andrea Efre, DNP, ARNP, ANP, FNP and Bryan Boling, DNP, AG-ACNP, CCRN-CSC, CEN
Systemwide Elements176
Anatomy and Physiology Review 176
Assessment 190
Diagnostic Studies 201
Patient Care 232

Specific Patient Health Problems 235

Acute Coronary Syndrome 235
Acute Myocardial Infarction—ST-Segment Elevation Myocardial Infarction 235
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 “Now you are going away because I have been disagreeable,”
remarked Madame Koller reproachfully. “And poor Ahlberg—”
“Must take care of you, and do his best to amuse you,” answered
Pembroke with a laugh and a look that classed Ahlberg with
Madame’s poodle or her parrot. “Good-bye,” and in a minute he was
gone. Madame Koller looked sulky. Mr. Ahlberg’s good humor and
composure were perfectly unruffled.
Hardly any one noticed Pembroke’s little expedition except Mrs.
Peyton and Olivia Berkeley. Mrs. Peyton mounted a pair of large
gold spectacles, and then remarked to Olivia:
“My dear, there’s French Pembroke talking to my niece, Eliza
Peyton—” Mrs. Peyton was a Peyton before she married one
—“Madame Elise Koller she now calls herself.”
“Yes, I see.”
“I suppose you saw a good deal of her in Paris, and my sister-in-
law, Sarah Scaife that was—now Madame Schmidt. She showed me
the dear departed’s picture the other day—a horrid little wretch he
looked, while my brother, Edmund Peyton, was the handsomest
young man in the county.”
“We saw Madame Koller quite often,” said Olivia. Mrs. Peyton
was amazingly clever as a mind reader, and saw in a moment there
was no love lost between Olivia Berkeley and Madame Koller.
“And that Mr. Ahlberg. Sarah Scaife says he is a cousin of Eliza’s
—I mean Elise’s—husband.”
“I should think if anybody knew the facts in the case it would be
Sarah Scaife, as you call her,” replied Olivia laughing. “I believe he is
a very harmless kind of a man.”
At that Mrs. Peyton took off her spectacles and looked at Olivia
keenly.
“I hate to believe you are a goose,” she said, good-naturedly; “but
you must be very innocent. Harmless! That is the very thing that man
is not.”
 “So papa says, but I think it comes from Mr. Ahlberg eating
asparagus with his fingers and not knowing how to play whist, or
something of the kind. I have seen him on and off at watering places,
and in Paris for two or three years. I never saw him do anything that
wasn’t quite right—and I never heard anything against him except
what you and papa say—and that is rather indefinite.”
“And you didn’t observe my niece with French Pembroke, did
you?”
Olivia Berkeley’s face turned a warm color. Such very plain
spoken persons as Mrs. Peyton were a little embarrassing. But just
then came the sound of the Colonel’s voice, raised at a considerable
distance.
“Olivia, my love—God bless my soul—Mrs. Peyton—there’s that
charming niece of yours—what a creature she was when she lived in
this county as Eliza Peyton—a regular stunner, begad—I must go
and speak to her—and my particular friend, Ahlberg—excuse me a
moment, my love.” Colonel Berkeley stalked across the track,
receiving all the attention which Pembroke had tried to avoid. Life in
his beloved Virginia had almost driven the Colonel distracted by its
dullness, and he could not but welcome a fellow creature from the
outside. He buttoned his light overcoat trimly around his still
handsome figure, and bowed majestically when he reached the
carriage. Madame Koller returned the bow with a brilliant smile. She
was beginning to feel very much alone, albeit she was in her native
county, and she welcomed Colonel Berkeley as a deliverer. Evidently
she soothed him about Dashaway. Pembroke, passing by, heard
scraps like the following:
“I have seen just such things at the Grand Prix—”
“Madame, the infernal system here of putting up irresponsible
negro boys—”
“I could see he had a superb stride—”
“Dashaway, Madame Koller, comes from the very best stock in
the State of Virginia.”
 The day wore on, and by dint of spinning things out most
unconscionably it was dusk of the clear autumn evening before the
cavalcade took the dusty white road toward home. In “the Isleham
carriage” Colonel Berkeley leaned back and waxed confidential with
his daughter.
“My dear, Eliza Peyton—Madame Koller I should say—is what
you young sprigs call green—excessively green. She imagines
because I am old I am a fool. And that precious scamp, Ahlberg—”
“Why do you call him a scamp, papa?”
“Why do I call Petrarch an African?”
“Mrs. Peyton seems to have some kind of a prejudice to Mr.
Ahlberg, too.”
“Aha, trust Sally Peyton to see for herself. She’s devilish tricky, is
Sally Peyton—not that I have any cause to complain of it—none
whatever. She’s very sharp. But we’ll go and call some day on Eli—
Madame Koller. She’s not bad company for the country—and I’ve
heard she could sing, too.”
“Yes, we will go,” answered Olivia, suppressing a yawn. “It’s in
the country, as you say.”
 CHAPTER II.
Does anybody ever ask what becomes of the prime donne who
break down early? Madame Koller could have told something about
their miseries, from the first struggling steps up to the pinnacle when
they can fight with managers, down again to the point when the most
dreadful sound that nature holds—so she thought—a hiss—laid
them figuratively among the dead. Nature generally works
methodically, but in Madame Koller’s case, she seemed to take a
delight in producing grapes from thorns. Without one atom of artistic
heredity, surroundings or atmosphere to draw upon, Eliza Peyton
had come into the world an artist. She had a voice, and she grew up
with the conviction that there was nothing in the world but voices and
pianos. It is not necessary to repeat how in her girlhood, by dint of
her widowed mother marrying a third rate German professor, she got
to Munich and to Milan—nor how the voice, at first astonishingly pure
and beautiful, suddenly lost its pitch, then disappeared altogether. It
is true that after a time it came back to her partially. She could count
on it for an hour at a time, but no more. Of course there was no
longer any career for her, and she nearly went crazy with grief—then
she consoled herself with M. Koller, an elderly Swiss manufacturer.
In some way, although she was young and handsome and
accomplished, she found in her continental travels that the best
Americans and English avoided the Kollers. This she rashly
attributed to the fact of her having had a brief professional career,
and she became as anxious to conceal it as she had once been
anxious to pursue it. M. Koller was a hypochondriac, and went from
Carlsbad to Wiesbaden, from Wiesbaden to Hyéres, from Hyéres to
Aix-les-Bains. He was always fancying himself dying, but one day at
Vichy, death came quite unceremoniously and claimed him just as he
had made up his mind to get well. Thus Eliza Koller found herself a
widow, still young and handsome, with a comfortable fortune, and a
negative mother to play propriety. She went straight to Paris as soon
as the period of her mourning was over. It was then toward the latter
part of the civil war in America, and there were plenty of Southerners
in Paris. There she met Colonel Berkeley and Olivia, and for the first
time in her adult life, she had a fixed place in society—there was a
circle in which she was known.
What most troubled her, was what rôle to take up—whether she
should be an American, a French woman, an Italian, a German, or a
cosmopolitan. For she was like all, and was distinctively none. In
Paris at that time, she met a cousin of her late husband—Mr.
Ahlberg, also a Swiss, but in the Russian diplomatic service. He was
a sixth Secretary of Legation, and had hard work making his small
salary meet his expenses. He was a handsome man, very blonde,
and extremely well-dressed. Madame Koller often wondered if his
tailor were not a very confiding person. For Ahlberg’s part, he
sincerely liked his cousin, as he called her, and quite naturally
slipped into the position of a friend of the family. Everything perhaps
would have been arranged to his satisfaction, if just at that time the
war had not closed, and French Pembroke and his brother came to
Paris that the surgeons might work upon poor Miles. They could not
but meet often at the Berkeleys, and Pembroke, it must be admitted,
was not devoid of admiration for the handsome Madame Koller, who
had the divine voice—when she could be persuaded to sing, which
was not often. He had been rather attentive to her, much to Ahlberg’s
disgust. And to Ahlberg’s infinite rage, Madame Koller fell distinctly
and unmistakably in love with Pembroke. If Ahlberg had only known
the truth, Pembroke was really the first gentleman that poor Madame
Koller had ever known intimately since her childhood in Virginia.
Certainly the wildest stretch of imagination could not call the late
Koller a gentleman, and even Ahlberg himself, although a member of
the diplomatic corps, hardly came under that description.
Pembroke had a kind of hazy idea that widows could take care of
themselves. Besides, he was not really in love with her—only a little
dazzled by her voice and her yellow hair. His wrath may be imagined
when after a considerable wrench in tearing himself away from Paris,
and when he had begun to regard Olivia Berkeley with that lofty
approval which sometimes precedes love making, to return to
Virginia, and in six weeks to find Madame Schmidt and Madame
Koller established at their old place, The Beeches, and Ahlberg, who
had been their shadow for two years, living at the village tavern. He
felt that this following him, on the part of Madame Koller, made him
ridiculous. He was mortally afraid of being laughed at about it.
Instead of holding his own stoutly in acrid discussions with Colonel
Berkeley, Pembroke began to be afraid of the old gentleman’s
pointed allusions to the widow. He even got angry with poor little
Miles when the boy ventured upon a little sly chaff. As for Olivia
Berkeley, she took Madame Koller’s conduct in coming to Virginia in
high dudgeon, with that charming inconsequence of noble and
inexperienced women. What particular offense it gave her, beyond
the appearance of following Pembroke, which was shocking to her
good taste, she could not have explained to have saved her life. But
with Madame Koller she took a tone of politeness, sweet yet chilly,
like frozen cream—and the same in a less degree, toward
Pembroke. She seemed to say, “Odious and underbred as this thing
is, I, you see, can afford to be magnanimous.” Colonel Berkeley
chuckled at this on the part of his daughter, as he habitually did at
the innocent foibles of his fellow creatures. It was very innocent, very
feminine, and very exasperating.
Nevertheless, within a week the big landau was drawn up, and
Colonel Berkeley and his daughter set forth, en grand tenue, with
Petrarch on the box, to call on Madame Koller. The Colonel had
never ceased teasing his daughter to go. Time hung heavy on his
hands, and although he had not found Madame Koller particularly
captivating elsewhere, and Madame Schmidt bored him to death
upon the few occasions when she appeared, yet, when he was at
Isleham, the ladies at The Beeches assumed quite a fascinating
aspect to his imagination. The Colonel had a private notion of his
own that Madame Koller had been a little too free with her income,
and that a year’s retirement would contribute to the health of her
finances. Olivia, however, believed that Madame Koller had but one
object in returning to America, and that was because Pembroke had
come. She remembered one evening in Paris, Pembroke had
“dropped in,” American fashion. The doctors had then said that
nothing could be done to restore poor Miles to comeliness—and
meanwhile, another blow had fallen upon the two brothers. Their
only sister, Elizabeth, a handsome, high spirited girl, older than they,
had died—and there had been a violent breach between her and
their father to which death alone put a truce. When the country was
overrun with troops, a Federal officer had protected the plantation as
far as he could, had saved the old father from the consequences of
his own rash conduct, and had taken a deep and tender interest in
the daughter. This was enough to blast Elizabeth’s life. She gave up
her lover—silently, but with a strange unyielding gentleness, she
kept aloof from her father. She was not condemned to suffer long.
The unhappy father followed her swiftly to the old burying ground at
Malvern. Men commonly seek distraction in griefs. Pembroke was
like the rest. He was popular, especially among the English colony
where his love of sports and manly accomplishments made him a
favorite—to say nothing of that prestige, which attaches to a man
who has seen service. He had gone into the war a lieutenant, and
had come out as major of his ragged, half-starved regiment.
Therefore when Pembroke idled and amused himself in Paris, for
some time Olivia could only feel sympathy for him. She knew well
enough that his means were small and the company he kept was
liable to diminish them—but after a while, she began to feel a hot
indignation against him. So on this particular evening, the Colonel
falling asleep opportunely, she took occasion to express her opinion
to Pembroke, that their ruined country needed the presence and the
service of every man she could call her own. Pembroke defended
himself warmly at first. He came for Miles’ sake—the boy whom he
had thought safe at school, and who ran away in the very last days
of the war to enlist—and almost the last shot that was fired—so
Pembroke said bitterly—disfigured the boy as he now was. Miles had
been eager to come, although Pembroke was convinced from the
beginning that neither the French, nor any other surgeons could
repair the work of that shot. He admitted that the boy had borne the
final decision with great manliness and courage “for such a little
chap,” the elder brother said fondly. When pressed hard by Olivia
about returning home, Pembroke though had no resource but
epigrams.
 “At all events,” she said presently, with a pretty air of heroism,
“Papa and I are going home just as soon as papa can do without his
crutch. Papa is a patriot, although he does talk so remarkably
sometimes.”
“Then, after you have got back, you can let me know how you like
Virginia as it is, and perhaps I will follow,” he answered, laughing in a
very exasperating way, Olivia thought. But when the Berkeleys got
home they found that the Pembrokes had arrived some weeks
before them—and soon afterward Madame Koller and her mother
turned up quite unexpectedly at their deserted old place, only to be
followed shortly after by Ahlberg, who, from his abode at the village
tavern rode over every day on a sorry nag, to see Madame Koller.
Imagine all this in a provincial country neighborhood!
Mr. Cole, the clergyman of Petsworth parish, was a bachelor, a
small, neatly-featured person, suspected of High Church leanings.
The Colonel had bluntly inquired of him if he intended to call on
Madame Koller.
“Hardly, I think, sir,” responded Mr. Cole, with much severity. “She
has not once been to church since she returned to the county—and
she only two miles off—and I hear that she and her friend Mr.
Ahlberg play billiards all day long Sunday, when they are not playing
cards.”
“Only the more reason for you to convert the heathen, ha! ha!”
answered the Colonel—“and let me tell you, Cole, if you hadn’t been
a clergyman, you would have been a regular slayer among the
women—and the heathen in this case is about as pretty a heathen
as you can find in the State of Virginia, sir.”
Evidently these remarks made a great impression on Mr. Cole,
for on the sunny afternoon, when Colonel Berkeley and Olivia drove
up to the door of The Beeches, they saw a clerical looking figure
disappear ahead of them within the doorway.
“The parson’s here, by Jove,” chuckled the Colonel.
The house was modern and rather showy. Inside there were
evidences that Madame Koller was not devoid of taste or money
either. The Berkeleys were ushered into a big square drawing-room,
where, seated in a high-backed chair, with his feet barely touching
the floor, was the little clergyman.
“Why, Cole, I am deuced glad you took my advice,” cried the
Colonel, advancing with outstretched hand and with a kind of hearty
good fellowship that pleased Mr. Cole, and yet frightened him a little.
He was a good soul and divided his small salary with his mother, but
he thought Colonel Berkeley’s society rather dangerous for a
clergyman. He used too many expletives, and was altogether too
free in his notions of what a churchman should be—for the Colonel
was a stanch churchman, and would have sworn like a pirate at
anybody who questioned his orthodoxy.
“Doing missionary work, hay, Mr. Cole?” continued Colonel
Berkeley, while Olivia and Mr. Cole shook hands.
A faint pink mounted into the clergyman’s face. His curiosity had
got the better of him, but the excellent little man fancied it was his
Christian charity that won the victory.
“Well, Colonel,” he begun, “upon reflection I concluded it was my
duty to call on Madame Koller. I wasn’t in this parish—in fact, I
wasn’t ordained at the time Madame Koller was Miss Eliza Peyton,
and Madame Schmidt was Mrs. Edward Peyton. And being the niece
of my excellent friend—Mrs. Sally Peyton—”
“Excellent friend, eh—well, don’t you trust Sally Peyton too far,
my good fellow. She was a mighty uncertain kind of a friend thirty or
forty years ago—not that I have any particular reason for saying so.
But you are quite right in paying your respects to Eliza Peyton—I
mean Madame Koller, and I only hope she’ll find our society
agreeable enough to stay here.”
A considerable wait ensued. Olivia had begun to wonder how
long it took Madame Koller to make a complete toilet, when a white
hand moved the curtain from a doorway, and noiselessly and gently
Madame Koller entered.
She was heartily glad to see them—their call was not very
prompt, but it would have been a cruel mortification had they omitted
to come. Olivia’s hand she pressed—so she did the Colonel’s—and
also Mr. Cole’s, who colored quite violently, although he struggled for
self-possession.
“We are very glad you have come,” said Olivia, with her sweetest
affability, “you will be a great acquisition to the neighborhood. You
see, I am already beginning to think more of our own neighborhood
than all the rest of the universe.”
“Thank you for your kindness,” answered Madame Koller, with
equal cordiality. The two women, however, did not cease to examine
each other like gladiators.
“And Mr. Cole, I think you were not here when I lived at The
Beeches as a girl.”
“No, madam,” replied Mr. Cole, who had now shaded from a red
to a pink.
“And did I not have the pleasure of seeing you at the Campdown
races the other day?”
Mr. Cole turned pale and nearly dropped off his chair. The
Colonel roared out his pleasant cheery laugh.
“No madam, you did not.” Mr. Cole made his denial so emphatic
that he was ashamed of himself for it afterwards.
“But you, Miss Berkeley, were there. My cousin Ahlberg saw you.
He praised you. He complimented you. ‘I have often seen that face,’
he said. ‘There are some faces which one remembers even in the
whirl of the greatest cities. I drive around the Bois de Boulogne—
once—twice—three times. I speak to a hundred friends. I see a
thousand faces. They pass before me like shadows of the night. One
face strikes me. It rises like a star from out the sea. Ah, I exclaim,
‘here is another photograph for my mental portrait gallery.’”
Neither the Colonel nor Olivia was fully prepared to accept
Ahlberg. Consequently, Madame Koller’s remark was received with a
cool smile by Olivia—and a sniff by the Colonel. But Mr. Cole was
quite carried away by Madame Koller’s declamatory manner, and her
really beautiful voice.
 “What a gift of tongues,” he said. “Madame Koller, if a—er—
public speaker—a religious instructor had your felicity of expression
—”
“I trust,” answered Madame, “some time to have the pleasure of
hearing your felicity of expression. I am not what you call a Christian.
I believe in a system of ultimate good—a philosophy if you will—”
“Yes, yes,” cordially chimed in Colonel Berkeley with something
dangerously like a wink, “I knew Madame, as soon as I saw you that
you believed in a system. It’s very useful and elastic and
philosophic.”
Madame playfully waved her hand at the colonel, and turned to
Mr. Cole.
“We will be friends, nevertheless,” she said with a captivating
smile. “I will visit your church in the morning, and you will return to
luncheon with me, and we will have a little game of billiards
afterward.”
Mr. Cole’s delicate face grew ashy. He, John Chrysostom Cole,
playing billiards on Sunday! What would his mother say—and what
would the bishop say! Olivia looked a little shocked because of
course Madame Koller must know better. Not so the Colonel. He
laughed heartlessly at Mr. Cole, and began to think Eliza Peyton was
a more amusing person than he had fancied.
“Madame Koller,” began Mr. Cole solemnly after a moment, “your
long absence from this country—your unfamiliarity with clergymen
perhaps—and with the American Sabbath—”
“Oh, yes, I remember the American Sabbath very well,” replied
Madame Koller laughing and raising her eyebrows. “My aunt, Mrs.
Peyton, always took me to church with her, and I had to listen to Dr.
Steptoe’s sermons. Oh those sermons! However,” she added,
turning her expressive eyes full on Mr. Cole. “I know, I know yours
must be very different. Well, I will go. And forgive me, if I sometimes
shock you—forgive and pity me.”
Mr. Cole thought that only a heart of stone could have hardened
against that pretty appeal. And the widow was so deliciously
charming with her half-foreign manner and her whole-foreign look.
But billiards on Sunday!
“Extend the invitation to me, ma’am,” said the Colonel. “I go to
church on Sunday—I have no system, just the plain religious belief
of a churchman and a gentleman—my ancestors were not a lot of
psalm-singing hypocrites, but cavaliers, madam, from the Court of
Charles the Second. But after I’ve been to church to please my
conscience and my daughter, I don’t mind pleasing myself a little. I’ll
play billiards with you—”
The door opened and Ahlberg appeared. Now Mr. Ahlberg was
not a favorite of Colonel Berkeley’s at any time—still less of Olivia’s;
but it was in the country, and it was very, very dull, so he got the
most cordial greeting he had ever had from either of them. The
conversation became general, and as soon as Ahlberg had the
opportunity, he edged toward Olivia. He was no gentle,
unsophisticated creature, like Mr. Cole. He knew that Olivia
Berkeley’s polite and self-possessed manner toward him concealed
a certain hardness. He made no particular headway in her good
graces he saw—and not much more in the Colonel’s. But both
gentlemen were hard up for amusement, and each was willing to be
amused, so, when Mr. Ahlberg, after a few well-bred vacuities with
Olivia, devoted himself to Colonel Berkeley, he was rewarded with
the intimation that the Colonel would call on him at the village tavern,
and this was followed up by another hint of a dinner invitation to
follow. This cheered Mr. Ahlberg very much, for to tell the truth he
was as near starvation as a man could be in this nineteenth century,
who had money in his pocket. If, however, Mr. Ahlberg had made it
his business to horrify Mr. Cole, he could not have done it more
thoroughly. He bewailed the absence of book-makers at the races,
and wished to know why elections were not held in America on
Sunday, took occasion to say that religion was merely an affair of the
State, and he too was a believer in a system. When they all rose to
go, poor Mr. Cole was quite limp and overcome, but he made an
effort to retain his self-possession. He urged both Madame Koller
and Mr. Ahlberg to attend the morning service on the following
Sunday. Both promised conditionally.
 The clergyman had walked over from the rectory where his
mother presided over his modest establishment.
“Come, Cole,” cried the Colonel, who was the soul of hospitality,
“here’s another seat in the carriage. Come back to dinner with us.
I’ve got some capital champagne, and Olivia will play for you.”
“I don’t care about the champagne, thank you,” answered Mr.
Cole, “but I’ll come for the pleasure of Miss Olivia’s playing and her
society also.”
Scarcely had the carriage turned into the lane, when Mr. Cole
burst forth:
“Miss Olivia, did you ever meet a more godless person in your life
than Mr. Ahlberg?”
“I don’t think I ever did,” answered Olivia, with much sincerity.
“But the widow—Eliza Peyton—eh, Cole? I think you have made
some headway there,” cried the Colonel, wagging his head at the
little clergyman. Mr. Cole’s heart began to thump. Strange it was that
although he ought, as a Christian and a clergyman, to disapprove of
Madame Koller with her beautiful blonde hair, he could not find it in
his heart to feel it. Nevertheless he could say it easily enough.
“I very much doubt, sir, the propriety of my visiting at The
Beeches.”
“Pooh, pooh. You’ll get over it,” chuckled Colonel Berkeley.
Ah, John Chrysostom! Has it never been known that the outward
man denounced what the inward man yearned and hankered after?
At this very moment do you not remember the turn of Madame
Koller’s handsome head, and the faint perfume that exhaled from her
trailing gown?
“We must invite them to dinner,” said the Colonel, decidedly.
“Cole, you must come, too. That poor devil, Ahlberg, is almost
starved at the tavern on fried chicken three times a day, and claret
from the tavern bar.”
 CHAPTER III.
A round of solemn afternoon dinings followed the return of the
Berkeleys to Isleham, and were scrupulously returned. But both the
Colonel and Olivia felt that it would not be well to include any of the
county gentry the day Madame Koller and Mr. Ahlberg were to dine
with them. Mr. Cole had already been invited—and Colonel Berkeley
of his own free will, without saying a word to Olivia, asked the two
Pembrokes. Olivia, when she heard of this, was intensely vexed.
She had used both sarcasm and persuasion on Pembroke in Paris to
get him home, and he had laughed at her. Yet she was firmly
convinced, as soon as Madame Koller expressed a determination to
come, either Pembroke had agreed, or else Madame Koller had
followed him—in either case Olivia was not pleased, and received
the Colonel’s information that the Pembrokes would be there sure in
ominous silence. Nothing remained but for her to show what a
remarkably good dinner she could give—and this she felt was clearly
within her power. She was naturally a clever housekeeper, and as
the case often was in those days, the freedom of the negroes had
made but little difference in the ménage at Isleham. Most of the
house servants had turned squatters on the plantation. Petrarch,
unpopular among his confrères because of his superior advantages
and accomplishments as well as his assumption of righteousness,
was the major-domo—and then there was Ike, a gingerbread colored
Chesterfield, as dining-room servant.
“Miss ’Livy, you jes’ let me manage dem black niggers,” was
Petrarch’s sensible advice. “Dey doan know nuttin’ ’bout a real swell
dinner. I say yistiddy to Cook M’ria, ‘Why doan yer have some
orntrees fur dinner outen all dat chicken an’ truck you has lef’ over
ev’y day?’ an’ Miss ’Livy, ef you will b’lieve me, dat nigger, she chase
me outen de kitchen wid a shovel full o’ live coals. She ain’ got no
’spect for ’ligion. Arter I got out in de yard, I say, ‘You
discontemptuous, disreligious ole cantamount, doan’ you know
better’n to sass de Lord’s ’n’inted?’” (this being Petrarch’s favorite
characterization of himself). “But M’ria ain’ got de sperrit ’scusin’ ’tis
de sperrit o’ owdaciousness. Ez fur dat Ike, I done tole him ‘I am de
Gord o’ respicution,’ an’ he ’low I ain’t no sech a thing. I gwi’n lick dat
yaller nigger fo’ long.”
“You’d better not try it Uncle Petrarch—” (Petrarch was near to
sixty, and was therefore by courtesy, Uncle Petrarch). “Ike won’t
stand it, and I won’t have it either, I can tell you.”
The Berkeleys went against the county custom, and dined in the
evening. Therefore, at seven o’clock precisely, on the evening of the
dinner, French Pembroke and his brother entered the quaint old
drawing-room at Isleham. Olivia had learned the possibilities of
ancient mahogany furniture and family portraits, and the great
rambling old house was picturesque enough. A genuine Virginia
wood fire roared up the chimney, where most of the heat as well as
the flame went. Wax candles, in tall silver candlesticks, were on the
mantel, and the piano. Miss Berkeley herself, in a white wool gown,
looked a part of the pleasant home-like picture, as she greeted her
two guests. French Pembroke had called twice to see them, but
neither time had Olivia been at home. This, then, was their first
meeting, except the few minutes at the races. He was the same
easy, pleasantly cynical Pembroke she had known in Paris. There
was another French Pembroke whom she remembered in her
childish days as very good natured, when he was not very tyrannical,
in the visits she used to pay with her dead and gone mother long ago
to Malvern—and this other Pembroke could recite wonderful poetry
out of books, and scare little Miles and herself into delicious spasms
of terror by the weird stories he would tell. But Miles had changed in
every way. He had been in his earlier boyish days the pet and darling
of women, but now he slunk away from the pity in their tender eyes.
He had once had a mannish little strut and a way of looking out of his
bold blue eyes that made a path for him wherever he chose to tread.
But now he shambled in, keeping as far out of sight as possible
behind the elder brother’s stalwart figure.
Colonel Berkeley shook Miles’s one hand cordially. His armless
sleeve was pinned up to his coat front.
 “God bless my soul,” the Colonel cried. “Am I getting old? Here’s
little Miles Pembroke almost a man.”
“Almost—papa—you mean quite a man. It is a dreadful reflection
to me that I am older than Miles,” said Olivia, smiling. Then they sat
about the fire, and Olivia, putting her fan down in her lap, looked
French Pembroke full in the face and said, “You know, perhaps, that
Madame Koller and Mr. Ahlberg dine here to-night?”
“Yes,” answered Pembroke, with all the coolness of conscious
innocence—or brazen assurance of careless wickedness, Olivia
could not tell which.
“You saw a good deal of them abroad, didn’t you?” was her next
question.
“Yes,” again replied Pembroke.
“Olivia, my dear,” said her father, who very much enjoyed this
little episode, “you women will never learn that you can’t find
anything out by asking questions; and Pembroke, my boy, remember
that women never believe you except when you are lying to them.
Let him alone, Olivia, and he will tell you the whole story, I’ll warrant.”
Olivia’s training had made her something of a stoic under Colonel
Berkeley’s remarks, but at this a deep red dyed her clear pale face.
She was the best of daughters, but she could at that moment have
cheerfully inflicted condign punishment on her father. Pembroke saw
it too, not without a little malicious satisfaction. She had quietly
assumed in her tone and manner that he was in some way
responsible for Madame Koller and her mother being at The
Beeches—an incident fraught with much discomfort for him—none
the less that there was nothing tragic about it, but rather ridiculous.
All the same, he determined to set himself right on the spot.
“Of course, I saw them often. It would have been quite
unpardonable if I had not, considering we were often in the same
places—and our land joins. I can’t say that I recollect Madame Koller
very much before she went away. I only remember her as rather an
ugly little thing, always strumming on the piano. I took the liberty of
telling both her and Madame Schmidt that I did not think they would
find a winter at The Beeches very pleasant—but it seems she did not
agree with me. Ahlberg is a cousin by marriage, and has been in the
diplomatic corps—”
And at that very moment Petrarch threw open the drawing-room
door and announced “Mrs. Koller and Mr. Ahlberg, sah.”
Madame Koller’s appearance was none the less striking in
evening dress, with ropes of amber around her neck, and some very
fine diamonds. Who says that women are indifferent to each other?
The instant Olivia beheld Madame Koller in her gorgeous trailing
gown of yellow silk, and her jewels, she felt plain, insignificant, and
colorless both in features, dress and manner—while Madame Koller,
albeit she knew both herself and other women singularly well, almost
envied Olivia the girlish simplicity, the slightness and grace that
made her a pretty picture in her white gown with the bunch of late
autumn roses at her belt.
The clergyman came last. Then Petrarch opened the folding
doors and announced dinner, and Colonel Berkeley gallantly offering
his arm to Madame Koller, they all marched in.
Something like a sigh of satisfaction escaped Mr. Ahlberg. Once
more he was to dine. Madame Koller sat on the Colonel’s right, and
at her right was Mr. Cole. The clergyman’s innocent heart beat when
he saw this arrangement. He still fancied that he strongly
disapproved of Madame Koller, the more so when he saw the
nonchalant way in which she took champagne and utterly ignored
the carafe of water at her plate. Mr. Cole took only claret, and
watered that liberally.
Madame Koller certainly had a very pretty manner—rather
elaborate and altogether different from Olivia’s self-possessed
simplicity. She spoke of her mother—“so happy once more to be
back in Virginia.” Madame Schmidt, always wrapped up in shawls,
and who never volunteered a remark to anybody in her life, scarcely
seemed to outsiders to be quite capable of any enjoyment. And Aunt
Peyton—dear Aunt Peyton—so kind, so handsome—so anxious that
people shall please themselves—“Upon my soul, madam,” cried the
Colonel, with much hearty good humor, “I am delighted to hear that
last about my old friend Sally Peyton. I’ve known her well for fifty
years—perhaps she wouldn’t acknowledge it—and a more
headstrong, determined, self-willed woman I never saw. Sally is a
good woman, and by heaven, she was a devilish pretty one when—
when—you may have heard the story, ma’am—but she always
wanted to please herself a d—n sight more than anybody else—
including Ned Peyton.”
The Colonel said this quite pleasantly, and Madame Koller smiled
at it—she seldom laughed. “Were you not some years in the army,
Colonel Berkeley?” she asked presently. “It seems to me I have
some recollection of having heard it.” Colonel Berkeley colored
slightly. He valued his military title highly, but he didn’t know exactly
how he came by it.
“The fact is madam,” he replied, clearing his throat, “in the old
days we had a splendid militia. Don’t you remember the general
musters, hay? Now I was the—the commanding officer of the
Virginia Invincibles—a crack cavalry company, composed exclusively
of the county gentlemen—and in some way, they called me colonel,
and a colonel I remained.”
“The title seems quite natural,” said Madame Koller, with a sweet
smile—“You have such a military carriage—that indescribable air—”
at which the Colonel, who never tired of laughing at other people’s
foibles, straightened up, assumed a martial pose, and showed vast
elation and immense pleasure—which Madame Koller saw out of the
corner of her eye.
Miles, sitting next Olivia, had grown confidential. “I—I—want to
tell you,” he said bashfully, “the reason why I didn’t come to see you
in Paris. It required some nerve for a fellow—in my condition—to
face a woman—even the best and kindest.”
“Was that it?” answered Olivia half smiling.
“You are laughing at me,” he said reproachfully.
“Of course I am,” replied Olivia.
A genuine look of relief stole into his poor face. Perhaps it was
not so bad after all if Olivia Berkeley could laugh at his
sensitiveness.
“So,” continued Olivia, promptly, “you acted like a vain, foolish
boy. But I see you are getting over it.”
“I’ll try. You wouldn’t treat me so cavalierly, would you, if—if—it
were quite—dreadful?”
“No, it isn’t dreadful at all, or anything like it,” replied Olivia, telling
one of those generous and womanly fibs that all true women utter
with the full approval of their consciences.
Meanwhile, Ahlberg and Pembroke had been conversing.
Ahlberg was indeed a clever fellow—for he talked in a
straightforward way, and gave not the slightest ground in anything he
said for the suspicion that Pembroke obstinately cherished against
him.
“What do you do with yourself all day, Miss Berkeley?” asked
Pembroke after a while.
“There is plenty to do. I have a dozen servants to manage that
ran wild while we were away—and the house to keep, and to look
after the garden—and I ride or drive every day—and keep up my
piano playing—and read a little. What do you do?”
“Nothing,” answered Pembroke, boldly.
Olivia did not say a word. She threw him one brief glance though,
from her dark eyes that conveyed a volume.
“I have a license to practice law,” he continued, coolly. “I’ve had it
for five years—got it just before the State went out, when I went out
too. Four years’ soldiering isn’t a good preparation for the law.”
“Ah!” said Olivia.
“I have enough left, I daresay, to keep me without work,” he
added.
If he had studied how to make himself contemptible in Olivia’s
eyes, he could not have done so more completely. She had acquired
perfect self-possession of manner, but her mobile face was as yet
undisciplined. When to this last remark she said in her sweetest
manner, “Won’t you let Petrarch fill your glass?” it was equivalent to
saying, “You are the most worthless and contemptible creature on
this planet.” Just then the Colonel’s cheery voice resounded from the
foot of the table.
“Pembroke, when I drove through the Court House to-day, it
made me feel like a young man again, to see your father’s old tin
sign hanging out of the old office, ‘French Pembroke, Attorney at
Law.’ It has been a good many years since that sign was first put up.
Egad, your father and I have had some good times in that office, in
the old, old days. He always kept a first-class brand of liquors. His
style of serving it wasn’t very imposing, but it didn’t hurt the liquor.
I’ve drank cognac fit for a king in that office, and drank it out of a
shaving mug borrowed from the barber next door—ha! ha!”
A change like magic swept over Olivia’s face. It indicated great
relief that Pembroke was not an idle scamp after all. She tried to look
sternly and reproachfully at him, but a smile lurked in her eyes.
“You are not as lazy as I thought you, but twice as deceitful,” she
said.
Pembroke was amused at the extreme suavity of the two ladies
toward each other, knowing that at heart it masked an armed
neutrality. Particularly did he notice it after dinner, when they
returned to the drawing-room and the piano was opened. Madame
Koller was asked to sing, but first begged that Miss Berkeley should
play. Olivia, without protesting, went to the piano. Her playing was
finished and artistic, and full of the delicate repose of a true
musician. When she rose Madame Koller overflowed with
compliments. “And now, madam,” said the Colonel, rising and
offering his hand with a splendid and graceful flourish, “will you not
let us hear that voice that charmed us when you were little Eliza
Peyton.”
Madame Koller did not like to be called Eliza Peyton—it was too
commonplace—Elise Koller was much more striking. And then she
was uncertain whether to sing or not. She had tried hard to keep that
stage episode secret, and she was afraid if she sang, that something
might betray her. She glanced at Ahlberg, as much as to say, “Shall