The PourConservation Principles

of Nursing

by Myra E. Levine, R.N., M.S.N.

APrinciPle is a fundamental concept which forms thebasis for a chain of reasoning. Formulated on a broadbase, it establishes the relationships between apparentlyotherwise unrelated facts. Nursing principles are funda-mental assumptions which provide a unifying structure forunderstanding a wide variety of nursing activities.

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The four principles discussed in this paper are all "con-servation" principles. Conservation means "keeping together"(L. conservatiov, but it should not imply minimal activity.In nursing, to keep together means to maintain a properbalance between active nursing intervention coupled withpatient participation on the one hand and the safe limits ofthe patient's ability on the other. Such a balance is struckonly when the patient's present needs, as assessed by thenurse, arc measured against the many variables that individ-ualize his predicament of illness. Then, since conservationtakes place within a space-time continuum, in planning nurs-ing care the nurse must allow for progress and change andproject into the future the patient's response to treatment.

The four conservation principles have as a postulate theunity and integrity of the individual. All nursing care isfocused on man and the complexity of his relationships with'lis environment, both internal and external, and commonexperience emphasizes that every response to every environ-mental stimulus results from the integrated and unifiednature of the human organism. In other words, every responseis an organismic one - no other kind is possible - andevery adaptive change is accomplished by the entire indi-vidual.

Adaptations vary considerably, however, in their quality.Every person possesses a unique adaptive capability, builton the extremely personal parameters which summarize hislife experience. The integrated response of the individual toany stimulus results in a realignment of his very substance,and in a sense this creates a message which others maylearn to understand. 1 Each message, in turn, is the result ofobservation, selection of relevant data, and assessment of thepriorities demanded by such knowledge.

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The patterns of adaptation contribute to a theoreticalframework to guide nursing care:

When nursing intervention can alter the course of theadaptation so that it is a good one (that is, in the directionof renewed social well-being). the nurse is acting in atherapeutic sense. When nursing intervention cannot alterthe course of the adaptation (that is, when the best effortscan only maintain the status quo or even fail altogether),the nurse is acting in a supportive sense. ~For a nurse to apply the four conservation principles, it

is essential that she identify the specific patterns of adapta-tion of every patient. Truly patient-centered plans for nurs-ing care are then possible.: Understanding the message andresponding to it accurately constitute the substance ofnursing science.

1. The Principle of the Conservation of Patient Energy

Nursing intervention is based on the conservation of theindividual patient's energy.

All of life's processes are fundamentally dependent uponthe production and expenditure of energy. The ability of anyperson to function is predicated on his energy potential andthe specific patterns of energy exchange available to him. Theintegrated response of the entire organism to environmentalstimuli is nowhere more apparent than in the assessment ofhis energy exchange. In addition, a variety of factors influ-ence the energy resource of every individual - factors whichin themselves define and describe his unique interaction withhis environment.

The nurse utilizes the patient's rate of energy consumptionas a means of measuring his tolerance to activities of allkinds. Time is therefore an important parameter of nursing

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care, and judgments which determine nursing decisions inthe patient's behalf are actually assessments of energy util-ization within a framework of passing time.

Disease processes of every kind create revisions in theenergy exchange for the individual, and his response todisease depends on the resource he possesses weighedagainst the demands made on his physiological function bypathological processes. Conservation of energy is typical ofnatural defense against disease processes. The lethargy andwithdrawal which accompany many acute disease conditionsdecrease the general demand on the organism for energyexpenditure and indicate that the physiological function ismobilized in the interests of the healing mechanisms. Such"biological priority" reflects the body's wisdom in defendingits ultimate well-being against the penalties of a specificpredicament. Nursing care can hardly do less.

Energy conservation during acute illness demands nursingintervention which cautiously balances the individual's re-source with the expenditure he can safely afford. The vitalsigns provide the nurse with some measurement of the wayin which the patient is utilizing his energy, but she alsoassesses this by observations of the patient's general condi-tion, his behavior, and his tolerance of the nursing activitiesrequired by his condition. Conscious attention to the rateof energy utilization allows for the anticipation of futureneeds in planning for the patient - a necessity when onerecognizes that evaluation of his condition has relevanceonly within a measured unit of time and that this time unit,too, is a variable which markedly influences any decisionsmade for the patient's continuing care.

The most obvious nursing consideration of energy con-servation is related to the pathophysiological condition which

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threatens the energy resource of the myocardium. Whensuch a condition is present, the entire body economy mustbe scaled to the energy requirements of the heart. This isthe primary problem in cardiac nursing. But the very factthat the circulatory system transports the nutrients andoxygen which are the fuel of energy transformations em-phasizes the need for conservation measures even when theprimary pathological condition is not in the cardiovascularsystem. Any insult to physiological function, however local-ized, may create systemic changes. Even a paronychia altersthe metabolism of the entire body when it is accompaniedby an elevation in temperature.

The presence or absence of life-threatening implicationsof a particular disease or condition is not necessarily amajor consideration in planning for energy conservation.The common cold exacts an expensive energy toll and, asthe old saw suggests, it follows a predictable course - oneweek with treatment and seven days without it. The knowl-edge of the expected course of the disease, modified bythe nurse's knowledge of the individual patient's resource,provides the substantive scientific base for nursing inter-vention. An upper respiratory infection in an otherwisehealthy adolescent is not the same as a similar infection ina seventy-year-old person in congestive failure.

Chronic disease represents an alteration in the individual'sability to adapt to the environment, and this alteration, too,involves a realignment of the energy resource available tothe individual. The development of chronic disease is alwaysaccompanied by a period during which relearning and re-adjustment must take place. There must be a successfuladaptation to the altered environmental interaction, but thisis a highly individualized response, and success is a matter

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of individual definition. Utter failure, of course, means thatlife is no longer possible.

Provision for the care of the chronically ill person requiresan evaluation of his available energy resource. Often thenurse can assist him best by helping him to strive for realisticgoals. The insulin-dependent diabetic patient who is main-tained on replacement therapy must learn to adjust hisinsulin-diet-activity triad to the vagaries of daily living.Although such reassessment is often less clear-cut whenchronic disorders have left the individual with irreversibledisabilities, it is nonetheless necessary in such circumstances.

Conservation of energy as a goal of nursing care requirescontinuing assessment of the effects of nursing activity. Therestoration of well-being and independent activity takes placegradually, and the nurse can guide the patient back toindependence only by recognizing the energy relationshipsas they are manifested by his response to care.

2. The Principle of the Conservation of Structural Integrity

Nursing intervention is based on the conservation oj theindividual patient's structural integrity.

The remarkable design of the human organism determinesthe way in which it functions. Structural change results ina change of function, and pathophysiological processes allpresent a threat to structural integrity. Healing processesare essentially predicated on the preservation of structureand the conservation of function within life-sustaining limits.In every instance of structural change, the localized inter-ference inevitably results in an organismic response, so thatonce more, the response of the entire organism defines thenurse's assessment of patient needs, and nursing attention

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must focus on the adaptive pattern as displayed by thespecific needs of the individual patient.

Tissue response to any kind of insult is aimed at therestoration of continuity. When the healing process cantake place with minimal structural change, as occurs inresolution, the defense effectively prevents functional aber-ration arising from structural change. However, when thesequelae of restoration result in the re-establishment ofcontinuity at the expense of structural organization, somefunctional disturbance is inevitable. Such a result is especiallyevident in highly differentiated organs, such as the liver orthe kidney, when fibrous tissue substitution assures healingbut does so at the sacrifice of the only structural patternthat permits adequate function. The mechanical disruptionof body structure, such as occurs when mitotic phenomenaencroach upon patent tubes or parenchymal organization oftissues, further illustrates the intimate dependence of functionon structure.

All varieties of surgical intervention are designed to restoreor redesign structural integrity. Simple re-establishment ofstructural form, such as the positioning of a fractured bone,the excision of an encroaching tumor, or the removal ofexpendable organs such as the appendix or gallbladder,requires nursing intervention which anticipates evidence ofreturning normal function. However, surgical procedures thatrestructure a body system, such as the shunting of the gutfor colostomy or the use of prosthetic devices in cardiacor vessel surgery, demand nursing orientation which expectschanging function. The amputation of a limb or of anybody part, while it preserves life, nevertheless results in arevised structure, and nursing consideration must be relatedto the consequent revision of function.

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The intimate relationship of structure and function is anequally important determinant of nursing care in nonsurgicaldisease entities. Not only does congestive heart failure in-volve the structural integrity of the circulatory system, butedema fosters functional changes that involve the entirebody. The nursing care is concerned with mobilization ofthe body fluids, and success of the treatment is dependentupon restoration of normal function. The concomitant vesselchanges in the insulin-dependent diabetic patient establishthe nursing evaluation of function in the care of such patients.

Every infection is an assault on structural integrity becauseit represents a competition in which some body cells mustbe destroyed. The defense response - the inflammatoryreaction - in itself may be potentially damaging unless itseffects arc limited and restrained as a result of the nursingintervention. Aseptic techniques provide the means for thiskind of nursing intervention.

Effective nursing care requires recognition of functionalchange in its earliest stages, and particularly when structuralintegrity is obviously threatened by disease. The dry noc-turnal cough that may accompany early left heart failureis .10 early subtle sign of functional disturbance, and itsrecognition permits therapy which will prevent the life-threatening symptoms of pulmonary edema.

The nursing priority placed on survival needs recognizesthat structural changes may become irreversible and thusalter function so that life is no longer possible. The dramaassociated with the emergency situation is lacking in theequally demanding problems of daily nursing care. Structuralintegrity is seriously threatened unless daily nursing care isfrankly rehabilitative in its intent. Increasing social concernwith iatrogenic, or physician-induced, disease should alert

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the nurse to the equally dangerous possibility of trophi-cogenic*, or nurse-induced, disease.

Nursing knowledge which can absolutely preclude troph-icogenic disease is available. Nursing practice must utilize it.The literature describes the structural damage which mayattend bed rest if nursing intervention does not prevent it.Anatomical positioning conserves the integrity of the skel-etal-muscular system. It is urgent in the care of the patientwith a cerebral-vascular accident, but is an issue for everypatient confined to bed for any length of time. Physiologicalpositioning can ensure maximal function of essential systems,such as the respiratory and circulatory systems. It may beurgent when the airway is threatened, but it is always aproblem in the patient who must remain in bed. The respon-sibility of the nurse for the maintenance of every patient'spersonal hygiene is related to the importance of asepticcontrol in the environment. The traditional emphasis on theimportance of a healthy and intact integument emphasizesthe nurse's role in conserving structural integrity. Range ofmotion and passive exercises are nursing measures whichcan be part of the daily care of patients.

3. The Principle of Conservation of Personal IntegrityNursing intervention is based on the conservation of theindividual patient's personal integrity.

Nurses need not be reminded that the body docs notexist separately from the mind, emotions, and soul. Con-servation of the patient's personal integrity is clearly a

"The word "trophicogenic" is the invention of Edwin B. Levine.Ph.D.. associate professor. University of Illinois at the ChicagoCircle. It IS based on the Greek. trophik 0.1 , (nursing care) and,1:('11;( (resulting from).

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nursing responsibility. Self-identity and self-respect are thefoundations of a sense of personal integrity. Illness threatensboth, and frequently the experience of hospitalization com-pounds and exaggerates the threat.

Nursing intervention must deal with the rights and priv-ileges of the individual in tangible ways. The assuranceof privacy during the performance of body functions andtherapeutic procedures of all kinds has been a concept thatpervades nursing care. It is sometimes not so clear that thepatient has a right to participate in the decision-makingrelated to his care, just as he possesses the right to consentto treatment in the first place. The emphasis on patientteaching recognizes the individual's right to be assisted inunderstanding the implications of his disease, his treatment,and his care. He must also be assured that his medical andsocial problems will remain privileged and confidential.

The nurse's regard for personal integrity may be valuedby the way in which she respects the importance the patientplaces on his personal possessions and by the mode ofaddress she employs when she is dealing with him, in oraway from his presence. Recently, Hall has described howimportant "proxcmics'" are in human interaction. and per-sonal integrity may well depend upon the ways in whichthe patient's perception of his space needs arc recognizedand protected by the nurse. I

Identification of defense mechanisms is essential to sen-sible nursing care. It is often therapeutic to support thepatient's defenses rather than try to provide a substitute for

.,A term ... for the interrelated observations and theories of man'suse of space as a specialized elaboration of culture. as used byDr. Edward T. Hall in Hidden Dimension, p. I. Garden City. N. Y.:Doubleday and Co., 1966.

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them. In any event, during an acute illness it is hardlyappropriate to demand new behavior patterns. Yet, nursesoften place the importance of routines above that of thepatient's needs. The patient soon learns that he is measuredaccording to how well he conforms to the nurse's expectationof him, and in doing so he sacrifices some of his integrity.

Every individual possesses a lifetime commitment to thevalue systems and social patterns of his subcultural affilia-tions. Dietary preferences arc obvious examples of thevariety of backgrounds to which the nurse must becomesensitive. Personal hygiene habits, sleeping patterns, anddeeply rooted perceptions of disease and its meaning arcalso common expressions of intense subcultural influenceon individuals. The stereotyped usc of white, middle-classvalue systems, with the aura of moral censure that oftencharacterizes such usc, can only limit the integrity of theperson whose values arc different, but nonetheless valid forhim. True conservation demands that the nurse accept thepatient the way he is. This may mean acceptance of situa-tions in which the patient chooses to ignore, deny, or evendeliberately flout the well-intentioned instructions of thenurse. Every individual must respond to illness on his ownterms, and the nurse must learn to allow the patient torespond in his own way without censure. Even when thepatient's behavior stirs disapproval, the nurse can strengthenhis self-respect.

The patient's pain. fear, guilt, loneliness, anxiety, anddifficulty in adjusting to unexplained routines and uncom-Iortablc treatments offer the nurse opportunities to supportand assist him so that his personal integrity is fortified.The technical skills of nursing. a "silent language" thatprovides the patient with confidence and security, arc

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fundamental to the success of any nursing task. It is onlywhen acceptance and sympathy - even love - are addedthat the dimensions of nursing care become great enough tomeasure a man on his own terms. No task is menial andno contribution small when nursing practice is characterizedby the nurse's honesty and willingness to cherish the integ-rity in every human being.

4. The Principle of Conservation of Social Integrity

Nursing intervention is based on the conservation 0/ theindividual patient's social integrity.

The human being knows himself in his reflection fromothers. The essence of his humanity is the result of hisdynamic relationship with other human beings. A manoutside the context of his social existence cannot be viewedas an integrated individual. Although illness and hospital-ization create isolation that is both physical and emotional,the social needs of the patient continue to require satis-faction.

The hospital possesses a social structure of its own, andalthough administrative necessity may encourage situationswhich the patient finds irrational and incomprehensible, henevertheless joins a community when he is there. He inevi-tably continues to function in a social milieu, howeverrestrictive it may be. The nurse can use his capacity forsocial participation in a variety of therapeutic ways.

Placement in the nursing unit should be considered onthe basis of the patient's social needs as well as his physicalneeds and should be determined with his interests as thecentral issue rather than the expediency of the admissionsdepartment. When the unit is shared with other patients,

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consideration of ethnic and subcultural affiliations maycontribute to his feelings of well-being. This grouping maybe particularly relevant when there is a shared language,but it is equally valid in connection with numerous othervariables, including age and degree of disability. The patient'sprivacy need not be sacrificed by encouraging interactionwith other patients. Such relationships develop in any event.and if they arc understood and acknowledged they can beused by the nurse to further the therapeutic process. Assimple a nursing act as positioning the patient in bed sothat he is able to socialize with his neighbors may ensurehis social interactions. Sensory deprivation is really socialdeprivation, and its effects arc only now beginning to receiveserious study.

In some cultures, the members of the patient's familyaccompany him to the hospital and remain with him, par-ticipating in his care. The traditional social isolation of theAmerican hospital. with its visiting restrictions and thelimitations placed on family participation in the care of thepatient, creates problems of patient management far moretroublesome than dealing with visitors. Some part of everyperson is left behind with those whom he can trust withouttesting and from whom he can expect love without justifyingit. The nurse has tended to make the patient her own, un-Willing to recognize that there arc others who care intenselyabout his welfare. At the time when the security of lovedones is most needed, for many patients it is entirely removed.The social conventions of get-well cards and flowers arc apoor substitute for the circle of familiar persons.

The most poignant examples of a failure to conservesocial integrity involve the critically ill or the dying patient.The opportunity for nursing the patient within the context

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of his family group, which entails providing the family aswell as the patient with knowledgeable support and assist-ance, is infrequently utilized by the nurse. In fact, thefamilies of dying patients arc often isolated and rejectedwhen they might be assisted to participate fully in this veryhuman experience. All of a man's life is woven in the fabricof his family, and denying him their ministration on theedge of death intensifies the fear and heartache for allconcerned.

Even the religious needs of the patient arc often handledin a most perfunctory way, Pastoral visits represent 41fundamental tic to the patient's identity with a communityand the importance of his participation in it. Other linksto the patient's community life can be provided by thehovpitul staff. There arc many jokes about the virtues ofchicken soup, the recognized cure-all in Jewish families.but ~I\ an ethnic symbol it opens the door in the wall thati~ placed around the hospitalized patient.

The patient often place!'> the nurse in surrogate roles,and she must understand them so that she can use themintelligently. But they arc only substitutes and are usefulonly to the degree that they aid the nurse in her task ofhelping the patient return to his own group. Such roles arcnot static: they tend to change as the patient's need forthem change. The gradual reintroduction to the communityi, typical of the patient's decreasing focus on himself ashi, ...yrnptom-, fade and his attention is redirected to hissocial life.' The usc of newspapers, magazines, radio, andtelevision, gauged to his tolerance and interests, contributesto his social convalescence.

The nurse's consideration for and interest in the patient'sfamily member!'> not only demonstrates his social integrity

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to him, but also lays the groundwork for the transition ofhis care into their hands. Teaching family members toperform specific necessary functions, such as changingdressings, administering medications, or preparing thera-peutic diets, is relatively easy when compared with helpingthem to prepare for the difficult adjustments in the homedemanded by a continuing convalescence or a disabilitywhich will persist.

Nursing is often defined as a nurse-patient interaction.This, too, is a social relationship, although it is one thatmust be disciplined and controlled by the professional roleof the nurse. Its importance to the patient is considerablymore than the mere fulfillment of his nursing needs. Theindividual's social integrity requires that he be a part of ahuman relationship, and his free participation acknowledgeshis worth. He C.lO sec his integrity mirrored in that of thenurse. The nurse's integrity is mirrored in him.

REFERENCES

I Wiener, Norbert, The Ifuman Use of If IIIIUIIl Beings, GardenCity. N. Y.: Doubleday & co.. I Doubleday-Anchor Books).1954. Sec esp. Chapter V. pp, 95-104.

C Levine. Myra E., "Adaptation and Assessment: A Rationalefor Nursing Intervention," A merican Journal of N lining;November 19M,

-- ---- - "Trophicognosis: An Alternative to Nurs-ing Diugnosis.' in l.x ptorim; Progrcs ill Medical-SurgicalNursing, Vol. 2. American Nurses Association: N. Y. \966.pp, 55-70.

I Hall. Edward T., The Hidden Dimension, Garden City. N. Y,:Doubleday and Co., 1966.

"Lederer, Henry D. "How the Sick View Their World," inl'utient, Plivvicians and lllncv, Ed. E. G, lace. Glencoe. III.:The Free Pre\o;. \95X. pp. 247-256.

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