The Pour

Conservation Principles
of Nursing
by Myra E. Levine, R.N., M.S.N.

PrinciPle is a fundamental concept which forms the

basis for a chain of reasoning. Formulated on a broad
base, it establishes the relationships between apparently
otherwise unrelated facts. Nursing principles are fundamental assumptions which provide a unifying structure for
understanding a wide variety of nursing activities.

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The four principles discussed in this paper are all "conservation" principles. Conservation means "keeping together"
(L. conservatiov, but it should not imply minimal activity.
In nursing, to keep together means to maintain a proper
balance between active nursing intervention coupled with
patient participation on the one hand and the safe limits of
the patient's ability on the other. Such a balance is struck
only when the patient's present needs, as assessed by the
nurse, arc measured against the many variables that individualize his predicament of illness. Then, since conservation
takes place within a space-time continuum, in planning nursing care the nurse must allow for progress and change and
project into the future the patient's response to treatment.
The four conservation principles have as a postulate the
unity and integrity of the individual. All nursing care is
focused on man and the complexity of his relationships with
'lis environment, both internal and external, and common
experience emphasizes that every response to every environmental stimulus results from the integrated and unified
nature of the human organism. In other words, every response
is an organismic one - no other kind is possible - and
every adaptive change is accomplished by the entire individual.
Adaptations vary considerably, however, in their quality.
Every person possesses a unique adaptive capability, built
on the extremely personal parameters which summarize his
life experience. The integrated response of the individual to
any stimulus results in a realignment of his very substance,
and in a sense this creates a message which others may
learn to understand. 1 Each message, in turn, is the result of
observation, selection of relevant data, and assessment of the
priorities demanded by such knowledge.

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The patterns of adaptation contribute to a theoretical

framework to guide nursing care:
When nursing intervention can alter the course of the
adaptation so that it is a good one (that is, in the direction
of renewed social well-being). the nurse is acting in a
therapeutic sense. When nursing intervention cannot alter
the course of the adaptation (that is, when the best efforts
can 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 adaptation of every patient. Truly patient-centered plans for nursing care are then possible.: Understanding the message and
responding to it accurately constitute the substance of
nursing science.
1. The Principle of the Conservation of Patient Energy

Nursing intervention is based on the conservation of the

individual patient's energy.
All of life's processes are fundamentally dependent upon
the production and expenditure of energy. The ability of any
person to function is predicated on his energy potential and
the specific patterns of energy exchange available to him. The
integrated response of the entire organism to environmental
stimuli is nowhere more apparent than in the assessment of
his energy exchange. In addition, a variety of factors influence the energy resource of every individual - factors which
in themselves define and describe his unique interaction with
his environment.
The nurse utilizes the patient's rate of energy consumption
as a means of measuring his tolerance to activities of all
kinds. Time is therefore an important parameter of nursing

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care, and judgments which determine nursing decisions in

the patient's behalf are actually assessments of energy utilization within a framework of passing time.
Disease processes of every kind create revisions in the
energy exchange for the individual, and his response to
disease depends on the resource he possesses weighed
against the demands made on his physiological function by
pathological processes. Conservation of energy is typical of
natural defense against disease processes. The lethargy and
withdrawal which accompany many acute disease conditions
decrease the general demand on the organism for energy
expenditure and indicate that the physiological function is
mobilized in the interests of the healing mechanisms. Such
"biological priority" reflects the body's wisdom in defending
its ultimate well-being against the penalties of a specific
predicament. Nursing care can hardly do less.
Energy conservation during acute illness demands nursing
intervention which cautiously balances the individual's resource with the expenditure he can safely afford. The vital
signs provide the nurse with some measurement of the way
in which the patient is utilizing his energy, but she also
assesses this by observations of the patient's general condition, his behavior, and his tolerance of the nursing activities
required by his condition. Conscious attention to the rate
of energy utilization allows for the anticipation of future
needs in planning for the patient - a necessity when one
recognizes that evaluation of his condition has relevance
only within a measured unit of time and that this time unit,
too, is a variable which markedly influences any decisions
made for the patient's continuing care.
The most obvious nursing consideration of energy conservation is related to the pathophysiological condition which

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threatens the energy resource of the myocardium. When

such a condition is present, the entire body economy must
be scaled to the energy requirements of the heart. This is
the primary problem in cardiac nursing. But the very fact
that the circulatory system transports the nutrients and
oxygen which are the fuel of energy transformations emphasizes the need for conservation measures even when the
primary pathological condition is not in the cardiovascular
system. Any insult to physiological function, however localized, may create systemic changes. Even a paronychia alters
the metabolism of the entire body when it is accompanied
by an elevation in temperature.
The presence or absence of life-threatening implications
of a particular disease or condition is not necessarily a
major consideration in planning for energy conservation.
The common cold exacts an expensive energy toll and, as
the old saw suggests, it follows a predictable course - one
week with treatment and seven days without it. The knowledge of the expected course of the disease, modified by
the nurse's knowledge of the individual patient's resource,
provides the substantive scientific base for nursing intervention. An upper respiratory infection in an otherwise
healthy adolescent is not the same as a similar infection in
a seventy-year-old person in congestive failure.
Chronic disease represents an alteration in the individual's
ability to adapt to the environment, and this alteration, too,
involves a realignment of the energy resource available to
the individual. The development of chronic disease is always
accompanied by a period during which relearning and readjustment must take place. There must be a successful
adaptation to the altered environmental interaction, but this
is a highly individualized response, and success is a matter

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of individual definition. Utter failure, of course, means that

life is no longer possible.
Provision for the care of the chronically ill person requires
an evaluation of his available energy resource. Often the
nurse can assist him best by helping him to strive for realistic
goals. The insulin-dependent diabetic patient who is maintained on replacement therapy must learn to adjust his
insulin-diet-activity triad to the vagaries of daily living.
Although such reassessment is often less clear-cut when
chronic disorders have left the individual with irreversible
disabilities, it is nonetheless necessary in such circumstances.
Conservation of energy as a goal of nursing care requires
continuing assessment of the effects of nursing activity. The
restoration of well-being and independent activity takes place
gradually, and the nurse can guide the patient back to
independence only by recognizing the energy relationships
as 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 the

individual patient's structural integrity.
The remarkable design of the human organism determines
the way in which it functions. Structural change results in
a change of function, and pathophysiological processes all
present a threat to structural integrity. Healing processes
are essentially predicated on the preservation of structure
and the conservation of function within life-sustaining limits.
In every instance of structural change, the localized interference inevitably results in an organismic response, so that
once more, the response of the entire organism defines the
nurse's assessment of patient needs, and nursing attention

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must focus on the adaptive pattern as displayed by the

specific needs of the individual patient.
Tissue response to any kind of insult is aimed at the
restoration of continuity. When the healing process can
take place with minimal structural change, as occurs in
resolution, the defense effectively prevents functional aberration arising from structural change. However, when the
sequelae of restoration result in the re-establishment of
continuity at the expense of structural organization, some
functional disturbance is inevitable. Such a result is especially
evident in highly differentiated organs, such as the liver or
the kidney, when fibrous tissue substitution assures healing
but does so at the sacrifice of the only structural pattern
that permits adequate function. The mechanical disruption
of body structure, such as occurs when mitotic phenomena
encroach upon patent tubes or parenchymal organization of
tissues, further illustrates the intimate dependence of function
on structure.
All varieties of surgical intervention are designed to restore
or redesign structural integrity. Simple re-establishment of
structural form, such as the positioning of a fractured bone,
the excision of an encroaching tumor, or the removal of
expendable organs such as the appendix or gallbladder,
requires nursing intervention which anticipates evidence of
returning normal function. However, surgical procedures that
restructure a body system, such as the shunting of the gut
for colostomy or the use of prosthetic devices in cardiac
or vessel surgery, demand nursing orientation which expects
changing function. The amputation of a limb or of any
body part, while it preserves life, nevertheless results in a
revised structure, and nursing consideration must be related
to the consequent revision of function.

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The intimate relationship of structure and function is an

equally important determinant of nursing care in nonsurgical
disease entities. Not only does congestive heart failure involve the structural integrity of the circulatory system, but
edema fosters functional changes that involve the entire
body. The nursing care is concerned with mobilization of
the body fluids, and success of the treatment is dependent
upon restoration of normal function. The concomitant vessel
changes in the insulin-dependent diabetic patient establish
the nursing evaluation of function in the care of such patients.
Every infection is an assault on structural integrity because
it represents a competition in which some body cells must
be destroyed. The defense response - the inflammatory
reaction - in itself may be potentially damaging unless its
effects arc limited and restrained as a result of the nursing
intervention. Aseptic techniques provide the means for this
kind of nursing intervention.
Effective nursing care requires recognition of functional
change in its earliest stages, and particularly when structural
integrity is obviously threatened by disease. The dry nocturnal cough that may accompany early left heart failure
is .10 early subtle sign of functional disturbance, and its
recognition permits therapy which will prevent the lifethreatening symptoms of pulmonary edema.
The nursing priority placed on survival needs recognizes
that structural changes may become irreversible and thus
alter function so that life is no longer possible. The drama
associated with the emergency situation is lacking in the
equally demanding problems of daily nursing care. Structural
integrity is seriously threatened unless daily nursing care is
frankly rehabilitative in its intent. Increasing social concern
with iatrogenic, or physician-induced, disease should alert

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

Nursing knowledge which can absolutely preclude trophicogenic disease is available. Nursing practice must utilize it.
The literature describes the structural damage which may
attend bed rest if nursing intervention does not prevent it.
Anatomical positioning conserves the integrity of the skeletal-muscular system. It is urgent in the care of the patient
with a cerebral-vascular accident, but is an issue for every
patient confined to bed for any length of time. Physiological
positioning can ensure maximal function of essential systems,
such as the respiratory and circulatory systems. It may be
urgent when the airway is threatened, but it is always a
problem in the patient who must remain in bed. The responsibility of the nurse for the maintenance of every patient's
personal hygiene is related to the importance of aseptic
control in the environment. The traditional emphasis on the
importance of a healthy and intact integument emphasizes
the nurse's role in conserving structural integrity. Range of
motion and passive exercises are nursing measures which
can be part of the daily care of patients.

3. The Principle of Conservation of Personal Integrity

Nursing intervention is based on the conservation of the
individual patient's personal integrity.
Nurses need not be reminded that the body docs not
exist separately from the mind, emotions, and soul. Conservation 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 Chicago
Circle. 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 the

foundations of a sense of personal integrity. Illness threatens
both, and frequently the experience of hospitalization compounds and exaggerates the threat.
Nursing intervention must deal with the rights and privileges of the individual in tangible ways. The assurance
of privacy during the performance of body functions and
therapeutic procedures of all kinds has been a concept that
pervades nursing care. It is sometimes not so clear that the
patient has a right to participate in the decision-making
related to his care, just as he possesses the right to consent
to treatment in the first place. The emphasis on patient
teaching recognizes the individual's right to be assisted in
understanding the implications of his disease, his treatment,
and his care. He must also be assured that his medical and
social problems will remain privileged and confidential.
The nurse's regard for personal integrity may be valued
by the way in which she respects the importance the patient
places on his personal possessions and by the mode of
address she employs when she is dealing with him, in or
away from his presence. Recently, Hall has described how
important "proxcmics'" are in human interaction. and personal integrity may well depend upon the ways in which
the patient's perception of his space needs arc recognized
and protected by the nurse. I
Identification of defense mechanisms is essential to sensible nursing care. It is often therapeutic to support the
patient's defenses rather than try to provide a substitute for
.,A term ... for the interrelated observations and theories of man's
use of space as a specialized elaboration of culture. as used by
Dr. 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 hardly

appropriate to demand new behavior patterns. Yet, nurses
often place the importance of routines above that of the
patient's needs. The patient soon learns that he is measured
according to how well he conforms to the nurse's expectation
of him, and in doing so he sacrifices some of his integrity.
Every individual possesses a lifetime commitment to the
value systems and social patterns of his subcultural affiliations. Dietary preferences arc obvious examples of the
variety of backgrounds to which the nurse must become
sensitive. Personal hygiene habits, sleeping patterns, and
deeply rooted perceptions of disease and its meaning arc
also common expressions of intense subcultural influence
on individuals. The stereotyped usc of white, middle-class
value systems, with the aura of moral censure that often
characterizes such usc, can only limit the integrity of the
person whose values arc different, but nonetheless valid for
him. True conservation demands that the nurse accept the
patient the way he is. This may mean acceptance of situations in which the patient chooses to ignore, deny, or even
deliberately flout the well-intentioned instructions of the
nurse. Every individual must respond to illness on his own
terms, and the nurse must learn to allow the patient to
respond in his own way without censure. Even when the
patient's behavior stirs disapproval, the nurse can strengthen
his self-respect.
The patient's pain. fear, guilt, loneliness, anxiety, and
difficulty in adjusting to unexplained routines and uncomIortablc treatments offer the nurse opportunities to support
and assist him so that his personal integrity is fortified.
The technical skills of nursing. a "silent language" that
provides the patient with confidence and security, arc

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fundamental to the success of any nursing task. It is only

when acceptance and sympathy - even love - are added
that the dimensions of nursing care become great enough to
measure a man on his own terms. No task is menial and
no contribution small when nursing practice is characterized
by the nurse's honesty and willingness to cherish the integrity in every human being.
4. The Principle of Conservation of Social Integrity

Nursing intervention is based on the conservation 0/ the

individual patient's social integrity.
The human being knows himself in his reflection from
others. The essence of his humanity is the result of his
dynamic relationship with other human beings. A man
outside the context of his social existence cannot be viewed
as an integrated individual. Although illness and hospitalization create isolation that is both physical and emotional,
the social needs of the patient continue to require satisfaction.
The hospital possesses a social structure of its own, and
although administrative necessity may encourage situations
which the patient finds irrational and incomprehensible, he
nevertheless joins a community when he is there. He inevitably continues to function in a social milieu, however
restrictive it may be. The nurse can use his capacity for
social participation in a variety of therapeutic ways.
Placement in the nursing unit should be considered on
the basis of the patient's social needs as well as his physical
needs and should be determined with his interests as the
central issue rather than the expediency of the admissions
department. When the unit is shared with other patients,

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consideration of ethnic and subcultural affiliations may

contribute to his feelings of well-being. This grouping may
be particularly relevant when there is a shared language,
but it is equally valid in connection with numerous other
variables, including age and degree of disability. The patient's
privacy need not be sacrificed by encouraging interaction
with other patients. Such relationships develop in any event.
and if they arc understood and acknowledged they can be
used by the nurse to further the therapeutic process. As
simple a nursing act as positioning the patient in bed so
that he is able to socialize with his neighbors may ensure
his social interactions. Sensory deprivation is really social
deprivation, and its effects arc only now beginning to receive
serious study.
In some cultures, the members of the patient's family
accompany him to the hospital and remain with him, participating in his care. The traditional social isolation of the
American hospital. with its visiting restrictions and the
limitations placed on family participation in the care of the
patient, creates problems of patient management far more
troublesome than dealing with visitors. Some part of every
person is left behind with those whom he can trust without
testing and from whom he can expect love without justifying
it. The nurse has tended to make the patient her own, unWilling to recognize that there arc others who care intensely
about his welfare. At the time when the security of loved
ones is most needed, for many patients it is entirely removed.
The social conventions of get-well cards and flowers arc a
poor substitute for the circle of familiar persons.
The most poignant examples of a failure to conserve
social 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 as

well as the patient with knowledgeable support and assistance, is infrequently utilized by the nurse. In fact, the
families of dying patients arc often isolated and rejected
when they might be assisted to participate fully in this very
human experience. All of a man's life is woven in the fabric
of his family, and denying him their ministration on the
edge of death intensifies the fear and heartache for all
concerned.
Even the religious needs of the patient arc often handled
in a most perfunctory way, Pastoral visits represent 41
fundamental tic to the patient's identity with a community
and the importance of his participation in it. Other links
to the patient's community life can be provided by the
hovpitul staff. There arc many jokes about the virtues of
chicken soup, the recognized cure-all in Jewish families.
but ~I\ an ethnic symbol it opens the door in the wall that
i~ placed around the hospitalized patient.
The patient often place!'> the nurse in surrogate roles,
and she must understand them so that she can use them
intelligently. But they arc only substitutes and are useful
only to the degree that they aid the nurse in her task of
helping the patient return to his own group. Such roles arc
not static: they tend to change as the patient's need for
them change. The gradual reintroduction to the community
i, typical of the patient's decreasing focus on himself as
hi, ... yrnptom-, fade and his attention is redirected to his
social life.' The usc of newspapers, magazines, radio, and
television, gauged to his tolerance and interests, contributes
to his social convalescence.
The nurse's consideration for and interest in the patient's
family member!'> not only demonstrates his social integrity

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to him, but also lays the groundwork for the transition of

his care into their hands. Teaching family members to
perform specific necessary functions, such as changing
dressings, administering medications, or preparing therapeutic diets, is relatively easy when compared with helping
them to prepare for the difficult adjustments in the home
demanded by a continuing convalescence or a disability
which will persist.
Nursing is often defined as a nurse-patient interaction.
This, too, is a social relationship, although it is one that
must be disciplined and controlled by the professional role
of the nurse. Its importance to the patient is considerably
more than the mere fulfillment of his nursing needs. The
individual's social integrity requires that he be a part of a
human relationship, and his free participation acknowledges
his worth. He C.lO sec his integrity mirrored in that of the
nurse. The nurse's integrity is mirrored in him.
REFERENCES

Wiener, Norbert, The If uman Use of If IIIIUIIl Beings, Garden

City. N. Y.: Doubleday & co.. I Doubleday-Anchor Books).
1954. Sec esp. Chapter V. pp, 95-104.
C Levine. Myra E., "Adaptation and Assessment:
A Rationale
for Nursing Intervention," A merican Journal of N lining;
November 19M,
-- - - - - "Trophicognosis: An Alternative to Nursing Diugnosis.' in l.x ptorim; Progrcs ill Medical-Surgical
Nursing, 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," in
l'utient, Plivvicians and lllncv, Ed. E. G, lace. Glencoe. III.:
The Free Pre\o;. \95X. pp. 247-256.
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