^Iw^S iffljjft i.iiV% I&&& ftg **/>./< 5¥V£» ##£ vi;^* #£& ?3m WY 100 H287t 1922 54130040R NLM DSEfiSDED fl NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W.D.S.G.O. ho.Z£30-*s' NLM052850208 TEXT-BOOK OF THE PRINCIPLES AND PRACTICE OF NURSING •y&/&&' THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO • DALLAS ATLANTA • SAN FRANCISCO MACMILLAN & CO.. Limited LONDON • BOMBAY • CALCUT- MELBOURNE THE MACMILLAN CO. OP CANADA. Ltd. TORONTO TEXT-BOOK OF THE PRINCIPLES AND PRACTICE OF NURSING BY BERTHA HARMER, B.Sc. (gSS^g^Y), R.N. Instructor of Theory and Associate Instructor of Practical Nursing, St. Luke's Hospital Training School for Nurses, New York; formerly Instructor of Theory and of Practical Nursing, and Supervisor of Nurses, The Toronto General Hospital Training School for Nurses, Toronto, Canada. THE MACMILLAN COMPANY 1922 All rights reserved PRINTED IN THE UNITED STATES OF AMERICA 100 Copyright, 1922, By THE MACMILLAN COMPANY. Set up and electrotyped. Published April, 1922. PREFACE The aim of this book is first to impress upon the student the fundamental principles of nursing, founded upon the ideals of service, its object being not only to help cure the sick and heal the wounded but to bring health and ease, rest and comfort to the suffering mind and body. Secondly, to emphasize the underlying principles of each practical procedure or treatment in addition to giving the method of procedure or technique. Only by a thorough education along these lines can the student reap the full richness from her profession or give to the patient the sympa- thetic, intelligent and skilled care necessary to his welfare and recovery. The text covers the fundamentals in nursing, namely, the nurs- ing care and treatments used in general medicine and surgery which are usually taught in the first and early part of the second year, the rest of the student's training being devoted to the spe- cial branches of nursing. The nursing care and treatments used in diseases of the eye, ear, nose and throat are also fully dis- cussed, because such care is frequently required in the general care of patients. The technique given is based not on that of any one hospital but on underlying principles so it may be adapted to any condi- tion or field of nursing, private or public, and to any hospital without interfering with one already established. The writer has attempted to give, in one volume, the results of a rather long and varied experience in teaching both theoretical subjects and practical nursing in the classroom and in the wards of more than one hospital as head nurse, supervisor, or instructor, together with a wealth of material drawn from numerous refer- ence books to which the average pupil does not have access. The text is presented from the teaching standpoint. The ma- terial is divided into elementary and advanced nursing and an effort has been made to follow an order, used in most hospitals, which will not only meet the needs in the ward but will carry the student along in a logical order from the simple to the more difficult procedures which require not only more skill but a wider knowledge and experience. The material is also divided into the two main divisions,— the nursing care and treatments used in medical diseases and those used in surgical diseases. This is the natural division of diseases which the nurse meets both in private nursing and in the hospital, since in private nursing a patient is in the care either of a physician or surgeon and in the hospital is nursed in v vi PREFACE either a medical or surgical ward. Lectures to students in medi- cal diseases are given by a physician, those in surgical diseases by a surgeon. It is hoped that this order of presentation will help in correlating the classes in practical nursing with the various lectures given and with the experience of the students on the wards. Also that it will eliminate much time, energy, and distraction in note-taking so that more time may be devoted to reports and discussions of the actual life on the wards. It is also very important that the study of practical nursing should, as far as possible, keep pace with the study of the various sciences. Particular attention has been given to the illustrations, 154 in number, consisting of photographs, diagrams and cuts. The writer is greatly indebted to Miss Isabelle Stewart, Pro- fessor of Nursing and Health, Teachers College, and to Miss Evelyn Carling, B.S. (Teachers College), Assistant Directress of Nurses, St. Luke's Hospital, New York, for reading the manu- script and for the very valuable criticisms given. I am also indebted to the various authors mentioned in the text, to Willard Bartlett, A.M., M.D., F.A.C.S., author of "After-treatment of Surgical Patients," to Frank Sherman Meara, M.D., Ph.D., author of "The Treatment of Acute Infectious Diseases," and to Miss Dorothy Reynolds, St. Luke's Hospital, for the original drawings in the chapter on bandaging. CONTENTS PART I ELEMENTARY NURSING CHAPTER I page Introduction.................. 3 The Object of Nursing: What It Is, and What It Includes. The Spirit, Ideals, and Point of View Desirable. The Kind of Qualities and Training Needed. Practical Nursing; Its Cor- relation with the Classroom; Its Supervision. The Facilities and Conditions Necessary for Training. CHAPTER II The Hospital as a Home for Sick People.........11 Functions of a Hospital; Classifications; Its Organization; Situation and Structure. CHAPTER III The Hospital Ward as a Home for Sick People. Ward Hygiene and Housekeeping...............14 The Surroundings of the Patient. Daily Care of the Ward. Ventilation. Heating and Temperature. Plumbing. Cleanli- ness and Means of Cleaning. Nature and Action of Different Cleansing Agents. The Ward Kitchen. Supply, Care and Use of Linen. Removal of Stains from Linen. Hospital Pests: Flies, Roaches, Bedbugs, Mosquitoes, Fleas Moths, Rats and Mice, Pediculi. CHAPTER IV The Hospital Bed: Its Equipment and Method of Making ... 33 The Bed and Its Equipment: Cost of Equipment. How to Make a Bed for a Sick Person. Care of Beds and Bedding. CHAPTER V The Admission of the New Patient..........37 Types of Patients. The Patient's Reception and Welcome. The Admission Bath. Care of the Hair: The Dangers, Symp- toms, and Treatment of Pediculosis. Respect and Care for the Patient's Personal Belongings. CHAPTER VI Observation of the Sick..............45 The Habit of Observation Essential in Nursing. The Nature of Symptoms and Physical Signs: Objective and Subjective Symptoms. Symptoms to Note in the Daily Care of Patients: Mental Condition; Physical Condition. Vlll CONTENTS CHAPTER VII How to Make a Helpless Patient Comfortable. Methods of Mov- ing, Turning, Lifting, Supporting, and Personal Care in Relation to Comfort.............. What Constitutes Comfort. The Importance of Comfort in the Care of the Sick. Causes of Discomfort in Illness: Physical Causes; Mental Causes. Means of Securing Mental Comfort. Means of Securing Physical Comfort: By Changing the Posi- tion of the Patient: Arrangement of Pillows; Method of Lifting a Patient in Bed; of Turning on One Side; of Sitting up in Bed; of Preventing from Slipping Down in Bed; of Sitting up in a Chair; of Putting Back to Bed; of Lifting a Helpless Pa- tient; of Turning a Mattress with a Patient in Bed, and of Moving a Patient from One Bed to Another. Water-Bed. Air Mattress. Padding and Bandaging Joints. Air and Cotton Rings. Cradles. The Nature, Causes, Symptoms, Means of Prevention, and the Treatment of Bedsores. CHAPTER VIII Rest and Sleep................. The Importance of Sleep. The Causes of Sleep and How to Secure Sleep. Preparation of the Patient for the Night: Rub- bing the Back. The Importance of Sleep for Infants and Children. CHAPTER IX The Morning Toilet............... The Beginning of a New Day for Patients and Nurses. Making a Bed with a Patient in it. A Bed-Bath. Care of the Mouth and Teeth. Mouth Washes. Care of the Hair: Washing the Hair. The Bathing of Infants and Children. CHAPTER X Feeding the Patient............... The Effect of Food in the Care, Comfort and Recovery of the Patient. The Kind of Food Required. The Effect of an Insuffi- cient Supply, Faulty Digestion, or Assimilation of Food. The Effect of Fever. Conditions which Favor the Digestion and Assimilation of Food. Rules to be Observed in Feeding Pa- tients. The Importance of Proper Feeding of Infants and Children. Method of Feeding Infants. The Feeding of Pre- mature Babies. Diet During the Second and After Years of Childhood. The Proper Method of Feeding Children. CHAPTER XI The Elimination of Body Wastes........... The Importance of the Elimination of Effete Materials in the Treatment of Disease. The Importance of Regularity in Defe- cation. Method of Giving and Removing a Bedpan. What to Observe about Feces. The Collection of a Specimen of Feces. Causes and Results of the Accumulation of Feces. Enemata; Purpose of the Cleansing Enema; Varieties of Cleansing Enemata; Local Remedial Applications: Enemata Given for a General Systemic Effect. Method of Giving a Cleansing Enema. Care of Rectal Tubes. Number and Char- acter of the Stools of a Normal Infant. Method of Changing an Infant's Diaper. The Formation of Regular Habits. CONTENTS IX CHAPTER XII page The Elimination of Body Wastes (Continued).......119 The Elimination of Waste Products by the Kidney. What to Note about Urine: The Normal Amount: The Causes, Symp- toms and Treatment of Retention; Nursing Measures to Cause the Patient to Void. Symptoms and Treatment of Suppres- sion. The Transparency, Color and Odor of Urine. The Col- lection of Specimens. Normal and Abnormal Constituents. The Amount and Character of the Urine of a Normal Infant. Collection of a Urine Specimen from an Infant. CHAPTER XIII The Cardinal Symptoms. Temperature, Pulse and Respiration : Temperature ................134 The Importance of Close Observation. The Body Temperature. The Production of Heat: Conditions which Increase and De- crease Heat Production. Heat Elimination. Heat Regulation. The Normal Body Temperature. Causes of Variations in the Temperature. The Temperature Curve. Types of Fever. The Clinical Thermometer. How and Where to Take the Body Temperature. Care of Thermometers. CHAPTER XIV The Cardinal Symptoms (Continued): The Pulse......152 The Pulse, What It Is. The Importance of Accuracy in Tak- ing and Recording the Pulse, Where the Pulse Can Be Taken. How to Feel the Pulse. The Normal Pulse. What to Note When Taking the Pulse: The Condition of the Wall of the Artery; The Tension or Compressibility of the Artery; The Blood Pressure; The Volume of the Pulse; The Size and Shape of the Pulse Wave; Rate of the Pulse; Rhythm of the Pulse. CHAPTER XV The Cardinal Symptoms (Continued): Respiration.....171 The Purpose and Importance of Respiration. Cause and Reg- ulation of Respiration. Normal Respirations or Breathing. The Method of Taking the Respirations. What to Observe When Taking the Respirations: The Rate and Character of the Res- pirations. The Temperature, Pulse, and Respirations During Infancy. CHAPTER XVI Elementary Nursing in a Medical Ward......... 185 Treatments: The Application of a Hot-Water Bottle; Local Hot-Air Bath; Fomentations or Stupes; Flaxseed Poultice; Mustard Poultice; Hot Foot-Bath; Mustard Plaster; Mustard Leaf; Ice-Bag. Conditions and Purposes for Which the Appli- cations are Used. The Causes, Symptoms, and Nature of an Inflammatory Process. The Action of Heat. The Action of Cold. CHAPTER XVII Elementary Nursing in a Surgical Ward........221 Mental and Physical Preparation of the Patient for an Opera- tion. Final Preparation of the Patient. Taking the Patient to the Operating-room. Preparation in the Ward for the Patient's Return: Ether-Bed. Bringing the Patient Back to the Ward: Care of the Patient on the Way Back. Care in the X CONTENTS Ward Discomforts Following Operations and Their Treat- ment. Diet. Care of the Aged After Operations. Care of Children after Operations. Treatments Used in the Surgica Ward; Vaginal Irrigation; Surgical Dressings; Making Surgical Dressings; Preparation of the Patient for a Dressing; Completing the Dressing and Making the Patient Comfortable. Sterilization of Instruments, Basins, Gloves, etc. Assisting with Dressings. CHAPTER XVIII Bandages, Binders, Adhesive Strapping.........257 Purposes for which Bandages are Used. Materials of which Bandages are Made. Types of Bandages and Their Uses. The Roller Bandage: Varieties in Width and Length; How to Make and Roll Bandages. Parts of a Roller Bandage: Principles to Observe in the Application of Bandages: Method of Securing a Bandage: Method of Removing a Roller Bandage: Funda- mental Bandages. Bandages Applied to Special Parts: Bandages of the Upper Extremity: Bandages of the Shoulder: Bandages of the Lower Extremity. Bandages of the Head. Bandages of the Chest. Plaster Bandages. Adhesive Strapping. The Bradford Frame. CHAPTER XIX The Departure of the Patient from the Hospital......301 Responsibility of the Nurse Toward the Patient. The Patient's Discharge. Care of the Body after Death. PART II ADVANCED NURSING CHAPTER XX Introduction. Inflammation and Congestion.......307 Definition. Steps in an Inflammatory Process. Measures Used to Regulate an Inflammatory Process: Rest, Position and Pres- sure, and Counterirritants. Meaning of Counterirritant. Action of Counterirritants. Anatomy and Physiology of the Struc- tures of the Body Chiefly Concerned in the Action: The Cir- culatory System, Skin, Nervous System. Summary of Way in Which Counterirritants Produce Their Effect. Degrees of Ir- ritation Produced. Rubefacients: Physical Agents, Chemical Agents, Mechanical Agents. Vesicants: Cantharides Plaster. Escharotics: Strong Acids, Alkalies, The Cautery, etc. PART II—A THE NURSING CARE AND TREATMENTS USED IN MEDICAL DISEASES CHAPTER XXI Nursing Procedures Used in the Treatment of Inflammation and Congestion : Rest, Position, Counterirritation, and Depletion 327 Physical Rubefacients: The Thermo-Cautery. Hot Sitz Bath. Chemical Rubefacients: Camphor, Iodine, Ammonia, Chloro- form, Turpentine, Ichthyol, Methyl Salicylate, Antiphlogistin. Mechanical Rubefacients: Dry Cupping. Vesicants: Can- tharides Plaster. Escharotics or Caustics: Acids, Alkalies, Metallic Salts, Carbon Dioxide, The Cautery. Depletion: Leech- ing, Wet Cupping. CONTENTS XI CHAPTER XXII rA.iE Nursing Procedures Used in the Treatment of Inflammation and Congestion (Continued): Minor Surgical Procedures . . . 346 Lumbar Puncture: Thoracic or Chest Aspiration. Aspiration of the Pericardium. Abdominal Paracentesis. Artificial Pneu- mothorax. Phlebotomy. CHAPTER XXIII Nursing Procedures Used in the Treatment of Inflammation and Congestion and Other Conditions (Continued): General Applications of Heat..............361 Effects of a General Application of Heat: Primary and Sec- ondary Effects. Effects of Prolonged Hot General Baths. Gen- eral Applications of Dry Heat: The Hot-Air Bath, Light Baths. General Applications of Moist Heat: The Vapor Bath, Hot Pack, Hot Tub Bath, Sedative Bath. CHAPTER XXIV Nursing Procedures Used in the Treatment of Inflammation and Congestion and Other Conditions (Continued): Local and General Applications of Cold...........374 Purposes for Which Local Cold Applications are Used. Purposes When Applied for a Purely Local Effect: The Effects Produced by Brief and Prolonged Local Applications. Alternate Local Applications of Heat and Cold. Conditions in Which Local Cold Applications are Contraindicated. Local Applications to Control the Circulation to the Part. Local Applications Made for a Reflex Effect on Some Internal Organ; Important Factors to Remember. Local Applications Used for a Secondary or Tonic Reaction: The Effects Produced. Local Applications of Cold: The Ice-Coil, Cold Head Compresses, Cold Chest Com- presses. General Applications of Cold: The Primary and Sec- ondary Effects of Brief and Prolonged Applications. Friction and Percussion. Conditions which Promote the Desired Reac- tion; Conditions which Discourage Reaction. General Cold Applications: The Cold Pack, Brand Bath, Cold Wet-Hand Rub, Cold Sponge Bath, Spray or Slush Bath. CHAPTER XXV Nursing Procedures Used in the Treatment of Inflammation and Congestion and Other Conditions (Continued): Douches and Miscellaneous Baths.............398 Effects of Hot and Cold Douches. Purpose of Douches. Con- traindications to the Douche. The Spinal Douche. Scotch Douche. Alternate Douche. Affusion. Miscellaneous Baths: Nauheim, Saline, Mustard, Alkaline, Emollient, Sulphur, and Alcohol Bath. CHAPTER XXVI Nursing Procedures Used in the Treatment of Diseases of the Alimentary Tract...............405 Gastric Lavage. Care of Stomach Tubes. Gavage. Nasal Gavage. Expression or Siphonage of Stomach Contents. Com- mon Test Meals: Ewald Test Meal: Macroscopic Examination of the Return. Microscopic Examination. Chemical Analysis. Riegel Test Meal. Fasting-Stomach Test. Salol Test. Method of Expressing the Stomach Contents. Xll CONTENTS CHAPTER XXVII pace The Administration of Medicines...........419 Responsibilities of the Nurse. To Insure Accuracy, Punctu- ality and Efficiency: The Doctor's Order-Book, Abbrevations, Medicine Chest, Method of Administration, Factors Modifying the Dosage. Channel of Administration: Intravenously (Sal- varsan and Neosalvarsan), Through the Lungs by Inhalation, by Hypodermoclysis, by Intramuscular Injection, Subcutaneously, by Mouth, by Rectum, by Inunction. CHAPTER XXVIII Nursing Care in Medical Diseases...........439 General Principles to be Considered. Nursing Care in Dis- eases of the Circulatory System: The Heart, Arteries and Blood. Nursing Care in Diseases of the Kidneys: Acute Nephritis, Chronic Nephritis, Uremia, Blood and Urine Tests. Diabetes Mellitus: Blood and Urine Tests. Medical Emergen- cies: Syncope, Collapse, Asphyxia, Drowning, (Artificial Res- pirations), Sunstroke, Heat-Stroke, Heat Exhaustion, Convul- sions, Apoplexy. CHAPTER XXIX Nursing Care in the Acute Infectious Diseases......475 General Principles to be Considered: Nursing Care to Prevent the Spread of the Disease, Fever or Pyrexia, Toxemia, Com- plications Apt to Accompany or Follow Infectious Diseases. Nursing Care and Treatments to Relieve Fever and Toxemia and Prevent Complications: Rest, Diet, Fresh Air and Gen- eral Hygienic Care, Local Applications and Hydrotherapy, Drugs, Sera and Vaccines, Convalescence. Typhoid or Enteric Fever. Pneumonia. Acute Rheumatic Fever. PART II—B THE NURSING CARE AND TREATMENTS USED IN SURGICAL DISEASES CHAPTER XXX The Preparation of a Patient for a Major Operation.....507 Examination of the Patient: Physical Examination, Examina- tion of the Urine and of the Blood. Preparation of the Patient, the Room, the Bedclothes. Positions Used for a Physical Ex- amination; Articles Required. Preparation of the Field of Operation: Preparation of the Nurse's Hands; "Wet Dressing" Preparation; Iodine Preparation. CHAPTER XXXI Nursing Care of the Patient, and Treatments Used Following an Operation.................519 General Care of the Patient. Colon Irrigation or Enteroclysis. Proctoclysis, or Murphy Drip Rectal Feeding or Nutritive Enema. Catheterization of the Urinary Bladder. Care of Catheters. Bladder Irrigation. Bladder Instillation. CONTENTS xm CHAPTER XXXII PAGE Nursing Care of the Patient, and Treatments Used Following an Operation (Continued).............543 Shock: Hemorrhage: Transfusion; Intravenous Infusion; Hypo- dermoclysis. Wound Infection: Conditions Which Promote Healing and Prevent Suppuration; Healing of Wounds: by Di- rect Union, by Granulating Tissue, etc. Symptoms of Wound Infection; Stitch Abscess: Suppuration. Complications in the Healing of Wounds: Scar Formation, Keloid, Ulcer Forma- tion, Sinus, Fistula. CHAPTER XXXIII The Prevention, Treatment and Nursing Care in Post-Operative Complications................570 Complications Resulting from an Infected Wound: Cellulitis, Septicaemia, Pyaemia, Erysipelas, Tetanus, Peritonitis, Pneu- monia, Renal Complications. Thrombo-phlebitis. Pulmonary Embolism. CHAPTER XXXIV Nursing Care in Operations Requiring Special Care in the After- Treatment.................583 Special Things to be Considered in the After-Care. Operations on the Jaw or Mouth. Exophthalmic Goiter. Breast Amputa- tion. Abdominal Operations: Herniotomy; Operations on the Stomach: Gastrostomy, Gastroenterostomy, Pylorectomy; Oper- ations on the Intestines: Hemorrhoids; Excision of the Rec- tum; Prolapse; Rectal Abscess; Operations on the Gall Blad- der and Ducts; Operations on the Urinary Tract. Operations on the Female Reproductive Organs. Perineorrhaphy. CHAPTER XXXV Nursing Care in Accidents and Emergencies.......599 Shock: Hemorrhage: Varieties or Classification, Symptoms, Nature's Reaction and Method of Control, Local Treatment of Hemorrhage, Systemic Treatment. Special Hemorrhages: Epistaxis, Hemoptysis, Hematemesis, Hemorrhage from the Uterus. Accidental Wounds: Contusions: Burns and Scalds: Frost-bites. CHAPTER XXXVI Nursing Care in Accidents and Emergencies (Continued) Injuries to Bones and Joints..............620 Sprains: Dislocations: Fractures: Varieties of Fractures; How to Recognize a Fracture; Complications Which May Occur or Develop; Repair of a Fractured Bone; General Factors to be Considered in the Treatment of Fractures; First-aid Treat- ment; Reduction and Immobilization; The After-care and Re- sponsibility of the Nurse. XIV CONTENTS PART II—C THE NURSING CARE AND TREATMENTS USED IN DISEASES OF THE EYE, EAR, NOSE AND THROAT CHAPTER XXXVII PAGE Nursing Care and Treatments Used in Diseases of the Eye, Ear, Nose and Throat...............643 Treatments to the Eyes: Examination of the Eyes; Instillation of Drops; Application of Compresses; Irrigations of the Con- junctival Sac; Eversion of the Lower Eyelid; Eversion of the Upper Eyelid; Application of Ointments, Powders, and Solu- tions; Removal of Foreign Bodies from the Eyes; Burns of the Eyes; Care of Artificial Eyes. Treatments to the Ear: Examina- tion of the Ears; Irrigations of the Ear; Myringotomy; Incision of Furuncles in the Aural Canal; Removal of Cerumen and Epithelial Plugs; Removal of Foreign Bodies from the Auditory Canal; Symptoms to be Watched for When Nursing Patients with Otitis Media. Treatments to the Nose and Throat: Ex- amination of the Nose and Throat; Sprays; Gargles; Throat Irrigation; Inhalations; Nasal Irrigation; Intubation; Trache- otomy. PART I ELEMENTARY NURSING I THE PRINCIPLES AND PRACTICE OF NURSING CHAPTER I INTRODUCTION THE OBJECT OF NURSING, WHAT IT IS, AND WHAT IT INCLUDES Let us begin by considering what the object of nursing is, so that we may have a goal to strive for, a guiding purpose by which we measure what we are and what we do and a central controlling idea by which we see the bearing and relation of all our studies and experience and which serves to link them together so that we may remember and utilize them. For, if we have a definite object in view, we are naturally interested in whatever leads us toward it and in what we are interested we eagerly pay attention, deriv- ing both pleasure and profit and learning, not without effort— for nursing demands our highest efforts—but with the effort which brings a glow of satisfaction for work well done. "The imagina- tion of great men feeds upon difficulties and exercises itself upon overcoming them." Nursing is rooted in the needs of humanity and is founded on the ideal of service. Its object is not only to cure the sick and heal the wounded but to bring health and ease, rest and com- fort to mind and body, to shelter, nourish, and* protect and to minister to all those who are helpless or handicapped, young, aged or immature. Its object is to prevent disease and to preserve health. Nurs- ing is therefore linked with every social agency which strives for the prevention of disease and the preservation of health. The nurse finds herself not only concerned with the care of the in- dividual but with the health of a people. Her influence is spread- ing far and wide and deep into the hearts and problems of the people. We find her, not only in positions such as Inspector of Training Schools, Hospital Superintendent, Instructor, Supervisor or Dietitian and Laboratory Expert, but engaged in the boundless field of Public Health, Social Service, School Nursing, Infant Welfare, Industrial Nursing, Rural Nursing, and other fields. An eminent critic has said that the final test, as portrayed in the last Day of Judgment, is a social test—did ye visit the sick, the poor, the hungry? Nursing includes all of this. 3 4 THE PRINCIPLES AND PRACTICE OF NURSING What Nursing Includes,—Many years ago Florence Night- ingale taught "that all disease, at some period or other of its course, is more or less a reparative process" and "that the symp- toms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the dis- ease at all, but of something quite different—of the want of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality, and care in the administration of diet, of each or of all of these,"—in other words,—in the want of good nursing, for nursing is concerned with and includes all of this. To-day Dr. Hare, an eminent authority in the treatment of dis- ease, in the directions given to his students, says: "In the treat- ment of all forms of disease the physician must never forget the following influential factors in the case, which are often of greater importance than the measures devoted to the treatment of the disease itself. 1. The maintenance of vital resistance by proper feeding. 2. The elimination of effete materials by the kidneys, bowels and skin. 3. The relief of annoying symptoms which sap the patient's vitality and often obscure the true state of the system. 4. That sufficient physical and mental rest and sleep are ob- tained if possible." Nursing is concerned with and includes all of this. It includes:—(1) The care of the patient's surroundings (which should be clean, attractive, quiet, orderly and comfortable) and of all things which add to his welfare and promote his recovery; (2) the personal care of the patient—bathing, feeding, making comfortable and attending to his personal wants, mental or physi- cal; (3) assisting the physician—preparing for and assisting with examinations, treatments, operations and tests, and observing and reporting the condition of the patient and results of treatments, etc.; (4) the administration of special diets, drugs and treatments, etc. ordered; (5) teaching—in the hospital the older nurses teach the younger nurses and each nurse consciously or unconsciously by example teaches the patients, especially the children, the standards of personal hygiene. In all public health work, the whole problem is being attacked on an educational basis. Nursing here is teaching the individual proper habits of living relating to food, rest, exercise, recreation, sleep, and all the conditions which insure health of body and mind and increased resistance to dis- ease; (6) informing the patients that, in the hospital, there is a Social Service Department which exists in order that patients, in need of its care, may consult with it and be relieved of financial difficulties and of worries regarding conditions in their homes. This department also makes provision for their con- valescence and will give instruction regarding their future health and care. It will take care of all matters which might hinder their present recovery, restoration to, and preservation of health. INTRODUCTION 5 Nurses should report to the Social Service Department all pa- tients who are in need of its care. THE SPIRIT, IDEALS AND POINT OF VIEW DESIRABLE Responsibility of the Nurse in her Relation to the Sick.— As stated above, nursing springs from the ideals of service, love and brotherhood—of service to those in trouble, sorrow, sickness or pain and in the time of death. There is no person (except pos- sibly the physician and the clergyman) who touches so closely the inner life of the people. The nurse is with them when all the conventions of life seem trivial, when all the barriers of re- serve are broken down and the innermost cherished and secret thoughts, hopes, and fears stand revealed. Sympathy, kindness and unselfishness are needed but also something more—something deeper and more helpful, more loving and spiritual which may support the patient with a feeling of strength, security, and com- fort. Now, while all may have this spirit of sympathy, kindliness and helpfulness, even to the degree of self-sacrifice, at the be- ginning of training, it must be very carefully cherished and de- veloped. If we neglect it and, day by day, in the rush, strain and fatigue, feel impatience and indifference, we may become incapable of feeling, and hardened. Nurses have sometimes, with justice, been accused of this. We must weed out such harmful thoughts and encourage kind thoughts and actions. No one be- comes kind except by being kind, and no one can win this spirit of love and service unless they, day by day, do acts of kindness. In no field is there such light and warmth and inspiration, such a rich opportunity for fullness of development. Dr. Osier has said: "There is no higher mission in life than nursing God's poor. In so doing, a woman may not reach the ideal of her soul; she may fall short of the ideals of her head; but she will go far to satisfy those longings of the heart from which no woman can escape." It is distinctly a woman's work—the one profession in which women are admitted by all to excel men. A cheerful, optimistic spirit is also very helpful both to the patient and the nurse. While the hospital is often a place of sad- ness, it is not one of gloom but often of rejoicing. It is our part not only to do the right things but to enjoy, to look and act as though we enjoyed. Gloom is most depressing to the mind and reacts very unfavorably on the patient's progress. Cheerfulness and optimism act as a tonic, or like sunlight which is now recog- nized as one of the great healers. Cheerfulness must not be con- fused with frivolity or thoughtless mirth which disregards the sor- rows of others. Sick people are very sensitive to the actions and presence of those around them. Happy persons bring new courage and give a new hold on life and this is valuable as the patient 6 THE PRINCIPLES AND PRACTICE OF NURSING must help himself to live, so that his mental attitude is important. A nurse can do much to cultivate this spirit both in herself and her patients. Reliability and trustworthiness in the care of patients and in carrying out instructions, which inspires the confidence of pa- tients, friends and superior officers. Obedience and willingness to be guided by those responsible for the care of the patients and by those responsible for and striv- ing for the interests and education of nurses. The Spartan spirit which will not flinch from duty, which makes light of discomforts and dangers, and welcomes hard tasks; which is firm and unyielding in the face of duty but avoids an antagonistic attitude. A professional spirit—a feeling of loyalty, not only to one's school but to the whole profession with a spirit of cooperation and desire to promote its interests as a whole. A scientific spirit which promotes a love of truth and avoids exaggerations and vague, misleading statements or actions, which is not influenced by sentimentality, which promotes a wholesome spirit of inquiry but never loses a feeling of wonder and reverence for the human body. A critical attitude toward one's own work which may be measured by the following results: (a) The speed and completeness of the patient's recovery. (b) The comfort and satisfaction, freedom from suffering and worry for the patient and relatives. (c) Economy of effort, time, and materials in nursing. (d) The neatness and finished appearance of the work. A spirit of appreciation of the work and all that it signifies. This includes (1) an esthetic appreciation in seeing a beautiful piece of finished work such as a beautifully made bed; (2) an appreciation or delight experienced in actually doing skilled work; (3) an appreciation of human nature, of the value of human life, of the greatness and weakness of humanity, of all its virtues and trials; (4) an intellectual appreciation in the sciences, etc., and study of diseases. Appreciation in all its phases must be devel- oped. It makes one fall in love with, become absorbed in, and thoroughly enjoy one's work. But one must avoid the danger of developing one at the expense of the other. For instance, our delight in making a bed quickly and skilfully and our pleasure in seeing it beautifully finished, if overstressed may make us for- get the patient in the bed so that he will be quite unable to ap- preciate it, however beautiful. Again our intellectual pleasure in learning may cause us to regard the patient as a "case" forgetting that he is a human being. "The intellectual faculties of memory, judgment and criticism in studies—leave the learner cold—he knows, but it does not make any difference to him, he lacks sym- pathy and understanding." It has been said that "a man's conscience is not the producer but the product of his career" and as ye sow ye shall reap; so that INTRODUCTION 7 habits of sympathy, of kindliness and patience, of thoroughness, persistence, and punctuality have a real moral value. A democratic spirit which leaves class and race prejudice be- hind. In a hospital it is the aim to give the same kind of care to men, women and children, to all colors and creeds, rich and poor, enemies and friends. THE KIND OF QUALITIES AND TRAINING NEEDED Health of mind and body which gives a wholesome, cheerful, sane outlook, steady nerves, a mind and body well under control with strength and endurance necessary to give the best care to the sick. Strength and vigor radiate from a healthy body and in- vigorate the weak. Knowledge.— 1. Of oneself—one's strength and weakness and capacities. 2. Of the sciences—anatomy and physiology, bacteriology, chemistry, physics, psychology and sociology, etc. 3. The household sciences—housekeeping, household manage- ment, dietetics. 4. The methods used in the prevention of disease and the pres- ervation of health—sanitation and personal hygiene, etc. 5. Disease and its treatments, etc. Trained Faculties.— 1. Manual dexterity is essential. The hands must be deft, strong and capable, quick and light but steady, firm but gentle, sensitive to impressions, never nervous or hesitating, but with a sure touch. 2. Trained senses (the eye, ear, sense of smell, taste and touch) —quick, keen, accurate observation, alert for signs which note improvement or danger—all the windows and doors of the mind open and a mind trained and educated to respond immediately in the right way. 3. Nerves cool and steady, a mind quick in seeing and grasp- ing things, resourceful, well-poised, quick-witted, undismayed by the unexpected, ready for emergencies. 4. Foresight, judgment, good sense and reasoning powers, de- cision, and fine discrimination. 5. A good memory, exact and reliable, which depends largely upon interest, attention and training. 6. A real interest in people, a desire for their welfare and the faculty of making this felt; tact, cooperation, the ability to handle people and get along with them—if this is lacking, all the other virtues, capacities and knowledge may be of little value. Learn to understand and influence people. 7. A manner pleasing, discreet and courteous, soothing, not irritating, winning the confidence of friends and patients, firm and unyielding in duty without antagonizing. 8. Expression—ability to control one's emotions, the voice quiet and gentle, the expression of the face kindly, serene, impas- 8 THE PRINCIPLES AND PRACTICE OF NURSING sive; ability to report, either in writing or orally, concise, clear, accurate statements unvarnished by sentiment. 9. Executive ability requiring foresight, the ability to or- ganize, of getting things done on time, of subordinating nonessen- tials to essentials, of keeping a number of things in hand at once, running smoothly with no excitement or confusion—the ability of managing affairs and people. PRACTICAL NURSING, ITS CORRELATION WITH THE CLASSROOM; ITS SUPERVISION The time spent by the student on the wards in the care of her patients is the most valuable, the most memorable in her train- ing. There is a wealth of priceless knowledge to be gained in the study of the patient. A nurse can gain knowledge regarding the patient himself, his history and social background, his symp- toms, the tests used in diagnosis, his treatment and the results. This is a study fascinating and stimulating to the mind, the imagination and the sympathies, and is capable of developing a large-mindedness, a breadth of view and purpose not found in other fields. It is here that the nurse develops not only skill, but develops also in sympathy, judgment, self-control, and in all the other qualities so desirable and necessary in a nurse. It is here that the nurse learns to tackle and solve problems efficiently, for this ability like every other ability can only come through prac- tice and training in doing. It is here that she becomes equipped to become a useful member of society for "education must proceed through the eyes and hands to the brain." Remember that a nurse is judged, not by what she knows but by what she does. As Ruskin says: "Education is not to make people know what they do not know, but to make them behave as they do not be- have." If nurses would remember this we would not hear com- plaints about the "overtrained" nurse or of the nurse "good in theory but hopeless on the wards." Everyone (children and grown folk) admires, respects, and has confidence in a person who can do things. It gives one influence and power and this power can only come from practice in doing. In after years the part that stands out in the memory of the nurse is the unforgettable knowledge gained in her experience on the wards. She feels that she has a firm grasp, which can never be taken away from her, and which cannot be bought or found in books. Knowledge which is in books may be learned at any time, but the experience on the wards can never be repeated— every moment is precious. All the time spent in the classroom, in the study of the sciences, etc., however interesting and instructive in themselves, is merely a preparation for the vital work on the wards. It throws light, supplies facts and underlying principles, and saves time. It makes the instruction more efficient, directs the attention, stimu- lates and excites the interest, organizes the knowledge gained on INTRODUCTION 9 the wards so that all students may share alike, and it gives the student tools to work with. The wards are the workshops where these tools are brightened and sharpened by application and use. The only sure test of the knowledge gained in the classroom is in its application or use in the care of the patients. As Dr. Osier used to say: "To study the phenomena of disease without books is to sail an uncharted sea, while to read books without patients is not to go to sea at all." Without the knowledge and the underlying principles studied in the classroom, to care for the patients on the ward is to "sail an uncharted sea," without a guide, helm or rudder. The practice is unsafe and the knowledge gained meager, haphazard, and un- sound and there is no provision for initiative and growth or a basis for constructive work. Supervision.—As the nursing is usually done by students, all of whom are in the process of learning, supervision of the work is absolutely essential if the care of the patient is to be satis- factory and if the student is to receive adequate instruction— for how can the blind lead the blind and how can they learn with- out a teacher? Even the best of us need to be spurred along at times and are glad to have standards kept before us which we are obliged to keep. The hospital has accepted a sacred trust in the care of the pa- tients who have confidence in and are entirely dependent upon the hospital, its doctors, and nurses. The reputation of the hos- pital and the welfare of the patients depend upon the quality of the nursing, and this depends to a large extent upon adequate su- pervision by qualified supervisors. Pupils are apt to misunder- stand and to resent this supervision whereas they should demand it as their right. They should recognize that this constant check- ing up is what upholds the standards of the school which at- tracted them to it and gives them reason to be proud of it. It is stated that much of the success of any school system depends upon the quality of supervision, and that expert constructive su- pervision is the most potent force, acting as a pressure on every- one to become stronger, more useful and efficient. Students frequently forget, misinterpret, or fail to apply what is taught in the classroom. The classroom teaching must, there- fore, be followed by inspection on the wards, for "Behold, a sower went forth to sow, and when he sowed, some seeds fell by the wayside, and the fowls came and devoured them up; some fell upon stony places where they had not much earth, and forth- with they sprung up, because they had no deepness of earth: and when the sun was up, they were scorched and because they had no root, they withered away. And some fell among thorns and the thorns sprung up and choked them. But others fell into good ground and brought forth fruit." The value of the supervision given will depend quite as much upon the student nurse as upon the supervisor. Supervision to be successful can never be one-sided. No matter how well-informed 10 THE PRINCIPLES AND PRACTICE OF NURSING and thoroughly equipped a supervisor may be to give advice, as- sistance, and instruction, and no matter how sympathetic and willing she may be to share her invaluable experience, her time and energy will be largely wasted, her results will be most dis- heartening, her efforts and good intentions will be entirely mis- understood and the student will profit very little if the student, herself, does not feel the need for guidance and instruction and look to the supervisor for it. Supervisors do not go about on the wards among the patients as inspectors or policemen to interfere, to find fault, to give orders, or to deprive the students of freedom, but as experts in the interests of both patients and students, ready to serve the patients dependent upon the nurses for their care, and to serve the students who have come to the hospital to be trained and educated in the difficult art and science of nursing. THE FACILITIES AND CONDITIONS NECESSARY FOR TRAINING There is only one place where nurses can learn to nurse and that is in the wards of a general hospital or in a hospital affiliated with other hospitals which round out their experience. All the knowl- edge necessary cannot, nor should not, be learned at once. The student goes through definite stages of learning, each of which prepares for the work which is to follow: (T) The probationary term, during which she becomes familiar with the hospital—its relation to the community, its various departments, their relation to each other and to the whole—and with the part she is to play in this great scheme of physical, mental and social betterment. During this period the student should become proficient in all that pertains to the care, comfort, and treatment of the convales- cent, the chronically ill, and the patients not acutely ill. She may also assist in the care of the acutely ill and in this way grad- ually acquire the art which nothing but experience can teach; (2) the junior, and (perhaps) part of the intermediate year, during which she becomes proficient in the care and treatment of medical and surgical diseases,—the remaining part of her training being devoted to the special branches in nursing and to experience in that branch to which she seems particularly adapted. This book follows the student in her work through the proba- tionary term, the junior, and part of the intermediate year only. CHAPTER II THE HOSPITAL AS A HOME FOR SICK PEOPLE The word hospital comes from hospes, which means host, and so a hospital embodies the idea of hospitality from a host or host- ess to her guests. Hospitals were originally guest houses for the shelter and entertainment of travelers, the words hotel and hospice coming from the same word. FUNCTIONS OF THE HOSPITAL To-day, modern hospitals are very highly specialized and com- plicated institutions and with a wide variety of activities and personnel. Their functions have been summed up under the fol- lowing seven heads: (1) The care of the sick; (2) the cure of the sick; (3) the education of the sick; (4) the training of the physicians; (5) the training of the nurses; (6) the extension of medical knowledge; (7) the prevention of disease. (8) They should function as social centers in the community. CLASSIFICATION OF HOSPITALS (a) According to Support and Control:— 1. Public, owned by the city or state, controlled by a commis- sion or board. The patients usually have free care. 2. Semi-public, usually built and maintained by a body of citizens, a church society or organization such as the Red Cross. Funds are supplied by public subscription, supplemented by ap- propriations from civic funds and answerable to the public. Other hospitals may be endowed and receive no support from the city or state. They are also supported by charges made to both public and private ward patients. 3. Private, owned by one or more individuals, and usually run for commercial gain or professional advancement. 4. Military hospitals, under the medical service of the army, with national support and control. (b) According to the Diseases or the patients treated:— 1. General, which accepts most types of diseases and patients. 2. Special, which may be limited to a certain type of disease as obstetrics, contagious, mental, etc., or may be confined to men, women, or children. Hospitals for the contagious or mental dis- eases may be under private support and control but are mostly controlled and supported by the city or state. Hospitals for ob- stetrics may be private, semi-public or public as regards their 11 ■ 12 THE PRINCIPLES AND PRACTICE OF NURSING support and control. General hospitals are usually supported as public or semi-public hospitals. Nurses should realize the sources from which the funds neces- sary to run the hospital are derived. In their attitude toward those responsible for running the hospital, toward the hospital itself, the care of equipment and supplies, and toward every- thing that pertains to the life and work within the hospital they should realize the difficulty each hospital has in securing adequate funds and the necessity for seeing that they are used to the best advantage for the purposes for which the hospital exists. ORGANIZATION OF THE HOSPITAL The organization varies but usually includes the following de- partments : 1. The Administrative Staff—the superintendent of the hospi- tal, clerks, bookkeepers, telephone operators, and other adminis- trative officers. They manage the business end of the hospital's duties and take care of the buildings and grounds. The superin- tendent is responsible only to the Board of Managers and lays down the general policies and coordinates the various services. 2. The Medical Staff—medical experts appointed by the Board, Attending Physicians (externes) and House Physicians (internes) who live in the hospital. Their duties are to diagnose, prescribe and administer treatments, to investigate and study dis- ease and to teach. 3. The Nursing Department, which may consist of graduate nurses only, with a Superintendent of Nurses in charge. It usu- ally consists of the Superintendent of Nurses or Principal of the Training School who has complete authority over the school and who is responsible to the Superintendent of the Hospital and the Board of Managers for the nursing service; assistant superinten- dent, instructors, head nurses and supervisors. 4. The Dietary Department with a dietitian in charge who is responsible for the food served to patients and staff, etc. She may be responsible to the Training School Department or directly to the Superintendent of the Hospital. 5. The Housekeeping Department with a matron in charge and maids, cleaners, laundry and linen room workers. 6. The orderlies on the male wards who have certain nursing duties and may also assist in the cleaning and care of the wards. 7. Technical Experts—pharmacist, anesthetist, pathologist, X-ray and electrotherapist, etc. 8. Social Service Department—nurses who investigate the homes of the patients where necessary and see that the home con- ditions are not such as to interfere with their recovery, and who see that the patients after discharge are able to and do carry out the prescribed treatment. For the proper administration of the hospital it is essential that every detail of hospital management should run smoothly, THE HOSPITAL AS A HOME FOR SICK PEOPLE 13 that every department should know its own work and carry it on effectively and that the various departments should work har- moniously together. The first thing is to get acquainted with the general scheme, the departments, the officers in charge, the gen- eral duties of each, the rules and regulations of the institution, and to learn to find your way about. The next thing is to get thoroughly acquainted with your own job, and learn to do it well. However simple the duties, they are always important to the smooth running of the institution. As soon as these first duties have been mastered new duties and increasing responsibili- ties will follow. Remember the whole purpose of nursing and of the hospital—to care for, to cure, to educate the sick and to prevent disease. The Nursing School is responsible to the patient, the hospital, and the community. ITS SITUATION AND STRUCTURE Its Situation.—Modern hospitals are usually built with care- ful attention to the situation and surroundings as it is now recog- nized that these have a definite relation to the nursing care and recovery of the patient. A hospital should be situated in a convenient place for the re- ception of patients, but if possible, on the outskirts of the city so that it will have plenty of pure air, free from dust, smoke, odors, etc., and quiet and seclusion from the noise and traffic of the city. If possible, it should be surrounded by well-kept, attractive grounds, with a dignified approach, which gives an air of order, quiet and restfulness, very beneficial to the patients. It should be built on an elevation in order to secure good drainage and plenty of light; not crowded or shut in by other buildings, and with a good outlook, a view of distance, very soothing and restful to the patients. The exposure should be southern or southwest, so as to have plenty of sun but avoidance of cold winds. Its Structure.—Modern hospitals are attractive, not harsh or forbidding in outline, built of the most durable, fireproof material. All the wards should be exposed to the sunlight with good ventila- tion. The interior—floors, walls, ceilings, etc.—should be made of durable material, easily kept clean, and smooth, so that the dirt won't stick, and free from ledges, crevices and decorations. The floors should be nonabsorbable and comfortable to walk on— tile or varnished oilcloth. The building should contain all mod- ern conveniences to save time, labor, and to insure efficiency at the least expense. While the older hospitals may not meet these requirements the disadvantages may be overcome as the quality of the nursing and their long and honorable service show. Such ideal conditions are very often not possible but in so far as the nurse can control the conditions, full advantage should be given the patients of fresh air, sunlight, a view from window or balcony of the blue sky, green trees and other growing things. CHAPTER III THE HOSPITAL WARD AS A HOME FOR SICK PEOPLE WARD HYGIENE AND HOUSEKEEPING THE STUDENT'S FIRST RESPONSIBILITIES The Surroundings of the Patient.—The ward is the special room set aside and prepared for the care and comfort of the guests who are to be our patients. Before the guest arrives his room must be prepared and in perfect order. It must be bright, airy, quiet, spotlessly clean, orderly, everything in its place, and attrac- tive in its simplicity. The patient and his friends should have a feeling of confidence and reliance on the care they are likely to receive. You know that in traveling in a strange country (and our patients must feel lonely, as though they were in a strange country on a long, doubtful journey) when entering an hotel, an appearance such as outlined is a sure index of the quality of the food and the service, etc., and you enter with a sense of relief and security. Whereas disorder, things out of repair, lack of cleanliness and system, and so forth, inspire a feeling of doubt which is very depressing, and which even very good food and service will not entirely dispel. In the care of the sick the nurse is the housekeeper, for housekeeping—the care of the patient's surroundings—is just as truly nursing, and the recovery of the patient is just as dependent upon it as upon the personal care of the patient himself. The furnishings of a hospital ward should be all plain, substan- tial, durable, smooth, free from decorations, and made chiefly of iron and glass which are nonabsorbent, easily cleaned, and which soap and water will not injure. They consist only of those ar- ticles essential for the care and comfort of the patients. The coloring of the walls and floor is always plain, free from pattern, cool, and restful to the eyes. This very simplicity, freedom from confusion and complexity is very restful to the patient, sick in mind and body, and is one of the essential factors in his recovery. Daily Care of the Ward.—The important factors to consider are its ventilation, heating, lighting, disposal of sewage, its clean- liness, neatness and order, and the general plan of work. The daily care of the ward begins with flooding it with sun- shine and fresh air, and in "tidying up"; that is, putting it in or- der. The beds should be neat and in line, the tables and chairs 14 HOSPITAL WARD AS A HOME FOR SICK PEOPLE 15 tidy, and in their proper places. All articles not in use should be removed and put in their proper place. The ward should present a picture of order, neatness, and symmetry, for nursing is an art and symmetry is the first essential in all art. After the floors are swept, beds, tables, chairs, screens, radiators, ledges, etc., are dusted and all utensils cleansed. Stand drawers are tidied and dusted, the patients' flowers are watered and arranged, all cupboards are dusted, their supplies checked, and neatly, sym- metrically arranged. All utility rooms, bathrooms, linen and blanket closets should receive the same care. Equipment and supplies necessary for the day's work are prepared. In beginning her duties, the nurse should have a definite plan of procedure so that her work may be accomplished with system and efficiency, without loss of time or energy. She should also plan her work so as to be able to meet extra demands or emer- gencies as they arise. The importance of the above factors—ventilation, lighting and cleanliness, etc.—in the recovery of the patient and the means of providing them, so as to get the best results, are discussed in the following pages. VENTILATION Proper ventilation or air control is an extremely important fac- tor in the maintenance of health and in the recovery from disease. Florence Nightingale has said that "The very first canon of nurs- ing, the first and the last thing upon which a nurse's attention must be fixed, the first essential to a patient, without which all the rest you can do for him is as nothing, with which I had al- most said you may leave all the rest alone, is this: To keep the air he breathes as pure as the external air, without chilling him." It has been said that "Air is the first necessity of life" and that "seemingly insignificant variations in temperature and humidity are now found to have an extraordinary effect on health in all parts of the world." x To insure ideal atmospheric conditions the following factors must be considered: (1) Temperature; (2) hu- midity; (3) movement; (4) variability; (5) purity. Temperature.—Conclusions drawn from very extensive studies of the effect of temperature on the health and energy of the body—based on the deaths following operations, and during the prevalence of disease and in a wide variety of conditions—show that the best average temperature for day and night is about 64° F., or from 64 to 68° during the day and a little lower at night. Too much emphasis cannot be placed upon this correct temperature, for "If the people could only be made to realize that the difference between 67° and 72°, for example, often means a difference of 5 per cent, in the death rate, they would think it worth while to take pains." 2 It can easily be demonstrated that 'Ellsworth Huntingdon, Ph.D., Yale University, 2 Ibid. 16 THE PRINCIPLES AND PRACTICE OF NURSING when people remain for a number of hours confined in a room at 75° F., there is an increase in the pulse rate and a rise of body temperature. The humidity is equally important and varies according to the temperature—the body is very sensitive both to changes in temperature and humidity. The best conditions exist with a tem- perature of 64° and humidity of 70 per cent. With the tempera- ture 64 (ideal) and lower humidity there is an increase in the death rate from 5 to 15 per cent., according to the drop in hu- midity. Very dry air makes people feel chilly because it causes so much evaporation one feels cool. Very dry air also makes people very sensitive to draft or movement of air. This causes them to close all the windows and doors, etc., and to demand more heat, not because the temperature is too low, but because the hu- midity is too low. The air then becomes stagnant and impure. On the other hand, when there is too much humidity droplets of moisture condense in the air, making it raw, cold, and clammy. When the temperature and humidity are just right the air feels soft, warm and spring-like. At high temperatures (above 70°) an increase in the humidity (above 60 to 70 per cent.) shows an increase in the death rate. At a low temperature an increase in humidity lowers the death rate. The temperature in the hospital should not be above 68° and the humidity not below 50 per cent. It is estimated that a proper regulation of the temperature would lower the death rate 5 per cent, and a proper regulation of the humidity another 5 per cent.1 Movement and Variability, that is, air in motion and with variations in the temperature.—These factors, also, if secured without causing chills, and increased dryness and temperature, are very beneficial to health, and aid in the recovery from disease. It has been estimated that proper air control in this respect would lower the death rate at least 3 per cent. These factors explain why outdoor air is so much more beneficial than indoor air. To quote from Dr. Ellsworth Huntingdon again: "Keep a patient in- doors with a uniform temperature of 68° and with an abundant supply of air which is absolutely fresh and pure, but which has no perceptible movement. Put the same patient out of doors in a tem- perature ranging from 60° in the morning to 70° at noon. Let him enjoy the fresh air as it sweeps gently across his face; let him feel the sudden little drop of temperature when a cloud obscures the sky, or when a pleasant breeze blows briskly for a minute. For hour after hour let him experience the tingle of strengthened circulation that comes with the constant movement and variation of the outside air. Everyone knows that the patient who is alternately soothed and stimulated in this way has a much better chance of recovery than the one who feels the same fresh air, is warmed by the same sun, and looks upon the same scene behind a barrier of windows which prevents perceptible move- 1 Ellsworth Huntingdon, Ph.D., Yale University. HOSPITAL WARD AS A HOME FOR SICK PEOPLE 17 ment or variation. Slight as is the difference between the outdoor and indoor air, its effect is almost magical. The difference lies in the degree of movement and especially of variability, for such variability is a universal quality of outdoor air in all good cli- mates." You have, no doubt, noticed that when a baby (or anyone) sleeps indoors his face usually becomes very hot and flushed looking and that he sometimes wakens very irritable. This is because while asleep he remains absolutely still so that the heat and moisture, constantly given off from his body, warms the air around it so that he is covered, as it were, with a hot moist blanket which becoming hotter than the body prevents further loss of heat and moisture because there is not enough movement in the air to carry away the hot oppressive air. When sleeping out of doors the movement and variability of the air insures a longer, healthier sleep from which one wakens refreshed. This movement and variability, together with sunlight, explain why soldiers in time of war, cared for in open tents, have fre- quently made such marvelous recoveries although deprived of proper food, medicines, treatments and nursing care which in the hospital are so essential. Modern hospitals and dwelling houses alike are now built with gardens, balconies, sunrooms and sleep- ing porches so that sick and well may have as much of the healing outdoor air and sunlight as possible. Pure Air.—Pure air means air free from gases and other products of combustion, free from dust which consists of inorganic and decaying organic matter, excretions from men and animals, molds and bacteria, etc.; free from impurities—gases and organic matter in the expired air from man or animals. Dust in the air is very irritating to the mucous lining of the eyes, nose and throat, causing abrasions, lowering the resistance and making them liable to infection. "Air is essential to life" and the essential factor in it is oxygen, which is necessary for the chemical changes which go on in the body, upon which life depends. The air inhaled consists of 20.81 per cent, of oxygen and 0.04 per cent, of carbon dioxid. After the exchange of gases which takes place between the air in the lungs and the blood, the exhaled air contains 16.03 per cent, of oxygen, 4.38 per cent. of carbon dioxid, organic substances, heat, and moisture. It is the heat and moisture given off, increasing the temperature and humidity of the air, which is injurious, rather than the impurities exhaled. However, a sufficient amount of air space (at least 2000 cubic feet) must be allowed for each patient. If the amount of oxygen falls to 13 per cent, one feels discomfort in breathing; if it falls as low as 8 per cent, one has great difficulty in breathing and asphyxia or smothering shortly follows. It is estimated that pure air would lower the death rate about 2 per cent. Methods of Securing Proper Air Control:— 1. The situation of the hospital, its structure and the relation 18 THE PRINCIPLES AND PRACTICE OF NURSING of its buildings—the wards away from the laundry, power house, garbage disposal, stables, kitchens, etc.—are all planned to secure ideal conditions. 2. The number and arrangement of beds so that each patient will have the required amount of air. 3. Modern hospitals are supplied with the indirect heating system by which, if properly managed, ideal conditions may be secured both summer and winter—the air being warmed in winter, cooled in summer, moistened, freed from impurities and forced into the room by fans, giving also movement and variability. By this method air treated with a disinfectant may be forced into the room. 4. Whatever the system of heating, there should be thermome- ters in each ward (several in large wards) and the temperature should not be allowed to go above 68° without steps to lower it. According to the system used, windows may be opened, the heat- ing system regulated by the local regulator, or by reporting to the proper authorities. A temperature chart should be kept with as much care, for it is equally important, as the temperature chart of the patient. 5. The humidity should not be below 50 per cent. Humidity is secured by evaporation—for instance from a kettle of boiling water on a stove or from pans of water on steam or hot water radiators. 6. To secure movement and variability keep the window open a little at the top. Open the windows every two or three hours and keep them open until the air cools 3 or 4 degrees. Open at both top and bottom having a deflector or board at the bottom to direct and control the current of air in order to prevent drafts. The warm air, and with it impurities, rises, so that the upper air is both hot and impure,—this will pass out the open window at the top while the cooler air will enter at the bottom, causing an entire circulation through the room. 7. While the room is being ventilated see that the patient is not in a draft and that he is properly covered with extra blankets if necessary. Place a screen between the window and the patient. Have him take deep breaths of the cool fresh air. Even greater precaution should be taken with a patient who is allowed up, for when a patient is in bed, properly covered and protected, there is little danger. But when up, his strength is probably being taxed to the utmost, his resistance is low, it is much more difficult to cover and protect him sufficiently so he is very apt to "catch" cold. It is not necessary for the air to be cold in order to be pure. If it is not desirable to open the windows in the patient's room, it may be ventilated by opening the door into an adjoining room which has been properly ventilated. It may be heated so that warm air enters the patient's room. See that the door does open into a well ventilated room and not into a stuffy room or passage or into a courtyard where the air is stagnant. 9. To prevent impurities in the air also see that all garbage, HOSPITAL WARD AS A HOME FOR SICK PEOPLE 19 waste and soiled dressings, etc., are promptly disposed of. Soiled dressings should be put in paper bags before placing in the gar- bage; garbage tins should always be kept covered, emptied fre- quently, and thoroughly cleansed and disinfected. All soiled utensils should be cleansed and disinfected immediately. Bed- pans, etc., after use should be covered immediately, cleansed thor- oughly, deodorized if necessary, and at all times kept scrupulously clean and odorless. The plumbing—sinks, hoppers, closets, etc.— often a source of odors or impurities, should be kept in proper order, with no leakage or stoppages, and kept clean, well flushed, and disinfected. HEATING Heating and temperature go together. Overheating causes bad ventilation; over-ventilating causes a large loss of heat. Types of Heating (Direct and Indirect) :— 1. Radiation, heat passing from a hotter to a colder body by means of rays—example, an open fireplace. 2. Conduction, when heat absorbed by any object passes from particle to particle through that object, as through the walls of a stove, a silver spoon in a cup of hot liquid, or through the metal handle of a kettle, etc.; most metals are good conductors. 3. Convection, a process by which heat is communicated through gases and liquids as a result of their mobility. For ex- ample, air in contact with a hot stove, warmed by conduction, rises, cold air takes its place so that convection currents of warm air are formed. When different parts of air or water are warmed to an unequal degree, there is a difference in weight also so that currents are formed; the warmer particles being carried to a dif- ferent position, give off some of their heat to cooler bodies or par- ticles by radiation and conduction. Means of Heating:— 1. An open fire place (direct radiation) which is a good ven- tilator and brings cheer, but is wasteful and provides an unequal heat. 2. Stoves which heat and ventilate but unequal gases and un- pleasant odors are given off. 3. Hot air furnace, which constantly pumps in fresh air so is a good ventilator but the air is much too dry, and gases with un- pleasant odor are given off. 4. Hot water and steam pipes which also dry the air (but less than hot air furnaces) unless provision is made for moistening the air by placing pans of water on the radiators, the water in which, when heated, is evaporated. 5. Electricity, which is clean and easily regulated, but expen- sive—not a ventilator. i 20 THE PRINCIPLES AND PRACTICE OF NURSING LIGHTING Lighting may be natural or artificial, and may be direct or in- direct. Natural Light—rays from the sun, through windows, etc.—is an extremely important factor and the hospital is built with a southern or southwestern exposure so that all the wards may be bathed in sunlight. Sunlight brings warmth and cheer; it is stimulating to the mind and body, and has great healing powers for mind and body which are now being utilized in the treatment of numerous diseases such as tuberculosis, anemia, and malnu- trition, etc. "It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close room, what hurts them most is a dark room. And that it is not only light but direct sunlight they want." x For this reason and for the benefits to be derived from the outside air—movement and variability, etc.—hospitals (and houses) are being built with sleeping porches so that every pa- tient, without being disturbed in his bed, may be moved out of doors and kept there as long as desirable. Sunlight is also one of the greatest purifiers and germ killers. No bacteria can stand or live in the penetrating rays of the sun for more than a short time—no room can remain musty and a mind can seldom remain gloomy in the healing light of the sun. "Put the pale withering plant and human being into the sun, and, if not too far gone, each will recover health and spirit." 2 "It is a curious thing to ob- serve how almost all patients lie with their faces turned to the light, exactly as plants always make their way towards the light."3 A nurse should therefore see that the ward is bathed in light, but that the shades are arranged so as to regulate the light and prevent it from shining in the eyes of the patient or from being a source of discomfort in any way. In certain cases it is neces- sary to almost entirely shut out the light—for instance, should the patient have sore eyes, following an operation on the eyes, or following an operation when sleep is desired and any outside stim- ulus—light, noise, etc.—is to be avoided; and in any condition when sleep is desired and in diseases mental or physical, when it is necessary to soothe, keep very quiet and free from stimulation. The artificial light used may be from candles, lamps, gas or electricity. In hospitals electricity is usually used. It is clean, produces no smoke, or foul air and little heat; it gives a good light, is very convenient, and easily managed. Electricity has practically no disadvantages except in the cost and its possible misuse. A nurse should use strict economy in the use of lights, 1 Florence Nightingale. 2 Ibid. 3 Ibid. HOSPITAL WARD AS A HOME FOR SICK PEOPLE 21 always turning them off when not required, also in reporting ex- posed wiring or any other disorder. PLUMBING The plumbing includes the water supply and sewage disposal. A nurse's duties regarding the water supply are to report any leaking taps which cannot be turned off; sinks or bathtubs, etc., with some obstruction to the outflow so that the water does not run away properly, and any odors from sinks, etc. The water should not be used for drinking purposes, without previously boil- ing, unless it is free from pathogenic germs. Impure water may cause indigestion, diarrhea, dysentery, poisoning or typhoid. Sewage disposal may be by the water carriage system or by the dry system (burning). The water carriage system is used in hos- pitals and consists of closets, hoppers, sinks, etc. This system in- cludes soil pipes, house drains, which carry the waste to the sewer, and intercepting traps, the purpose of which is to prevent foul air from the drains escaping into the dwelling. Great care must be taken to prevent the drains from becoming choked. Plumbing repairs are very costly and plumbing in disorder causes great in- convenience and discomfort. The obstruction is usually due to matter or objects which should never be thrown into closets or hoppers, etc.—cotton waste, matches, hair, paper, grease and other articles which through carelessness are thrown in. Nurses should be extremely careful themselves and should instruct both patients and maids in the proper use of the plumbing. Report that the closet, etc., is choked if (1) the level of the pan or bowl remains the same; (2) if the plug is pulled, the con- tents rise and the water does not flow into the trap; (3) if there is a leakage at the joint at the foot of the basin; (4) if bubbling occurs in the pan or bowl; (5) if there is a foul odor—do not use. CLEANLINESS Cleanliness of floors, walls, ceilings, furnishings, and utensils, etc., is equally important with lighting and airing. There can be no true ventilation, which includes the removal of all impurities from the air of a room, as long as articles or any part of that room is dirty. It is useless to talk of ventilation, when every movement of air merely serves to scatter dust from surfaces, where it is relatively harmless, into the air to be inhaled by those in the room. Dust always harbors bacteria, and the dust in hospitals always harbors very virulent bacteria, because they have been discharged from the bodies of human beings where they have been strengthened because living under conditions most fa- vorable to them and so have become very dangerous to man. Be- fore the days of scientific cleaning in hospitals, almost every pa- tient who entered contracted a sore throat, due to microorganisms, which was spoken of as "hospital sore throat." To-day this is 22 THE PRINCIPLES AND PRACTICE OF NURSING almost unknown, but would again become universal should the constant attack on dust, dirt, and body excretion be relaxed. Cleanliness is one of the strongest supporters of good health; it affects both the mental and physical health and is a powerful prophylactic against disease. Dirt is offensive to the senses of sight, smell, touch, or taste, causing one to shrink from it. It symbolizes everything that is offensive to the senses and there- fore to the mind. It depresses and inhibits the functions of both mind and body. Dirt means lack of comfort, decency and self- respect. Absolute cleanliness means freedom from germs or any- thing which will harbor germs. Modern surgery is based upon this and it is its first principle. It is the keynote in the cam- paign for the prevention of disease and the preservation of health. The art of cleaning, therefore, is included in, and is inseparable from the art of nursing. The more ambitious a student is in her profession—whether to become a superintendent or a leader in public health work,—the more essential is a true, practical knowl- edge of the art of cleaning in the most efficient, economical, time and energy saving way. Housekeeping may be mere drudgery or it may be an art and is now one of the sciences taught in some of the modern colleges. It is idle to talk of nursing and it is idle to talk of public health work which includes teaching habits of cleanliness, both of person and surroundings, and teaching not by talking but by demonstrating, without a practical knowledge of cleanliness. This knowledge, like all other knowledge, can only come by doing. Cleanliness also trains a nurse in habits, essential to success in nursing, such as habits of thoroughness and deftness, method in planning her work, of going about quickly, quietly, and in a purposeful way, and in the care and economical use of equipment and supplies. Dirt or dust consists of: 1. Organic matter (the product of life)—dried excretions and discharges from the body, scales of dead skin, food and grease, etc. 2. Inorganic matter—sand, minerals, etc. Its danger lies in its constant tendency to settle in dark, damp, warm, out of the way places, apt to be overlooked, and away from air currents so that it forms a lurking place for germs. It forms an excellent soil for their growth, and when carried into the air is very irritating to the mucous lining of the nose and throat, etc., and may cause infection. As previously stated, the germs harbored in a hospital are often very virulent, and the re- sistance of the patients in a hospital is greatly lowered. The removal of this dirt, then, is essential because, (1) It en- dangers the health; (2) it has a depressing effect on the mind; (3) it is a cause of irritation to mucous membranes; (4) it may spread disease. Removal does not mean stirring up or scattering from one place to another—much better leave it alone unless it is actually removed. Dirt is removed by sweeping, washing and HOSPITAL WARD AS A HOME FOR SICK PEOPLE 23 dusting; a nurse usually is held personally responsible for the dusting only. The principal points to consider in dusting are: (1) To have the right attitude toward the work; (2) to dust after, not before sweeping; (3) to use clean water and a clean duster; (4) to use a damp (not wet) cloth, to which the dust particles will adhere, for all surfaces except electric fixtures and polished furniture; (5) to dust with a firm, even stroke, not round and round; (6) to dust thoroughly going well into corners, etc.; (7) to have a system in working avoiding waste of time and energy; (8) to be economical in the care and use of materials; (9) to do finished work, using a dry duster to dry or polish the surface, and arrange articles, table, chair, etc., in order. The means of cleaning will depend upon the material to be cleansed, the nature of the dirt, and economy in the use of ma- terials. Nurses may have to select or order the agents used for various housekeeping duties such as cleaning, washing out special materials, removing stains or body discharges from linen, etc., so it is important to know the nature and action of the various agents used. Nature and Action of Different Cleansing Agents.—1. Na- ture's purifiers—the sun, air and water. These stand first because they are always available, are found everywhere, cost nothing, being free to everyone, and are indispensable. As stated pre- viously, sunlight kills bacteria, molds, and other lower forms of plant life. The sun, air and moisture break up harmful sub- stances and render them harmless. The oxygen in the air, because of its readiness to combine with other substances, breaks up both organic and inorganic substances, making them harmless. Water is the universal solvent and it also carries the dirt away. Hot water dissolves fat; cold water dissolves albumen in blood, feces, or any discharge from the body. 2. Solvents.—Soft water is the best solvent but frequently contains dirt which it gathers in its passage. A temporary hardness of water is due to a soluble lime com- pound (the salts are compounds of calcium or magnesium and carbonic acid), which will combine with soap and form a greasy scum unless the water is previously boiled. This causes the lime to settle out. Water with a temporary hardness, then, may be softened by boiling. The hardness is said to be permanent when not removed by boiling. The compounds are not carbonates but sulphates of magnesium or calcium. This hardness may be removed by adding an alkali, such as sodium carbonate, borax, or ammonia, before boiling. The alkali enters into combination with the salts in solution and changes them from sulphates into insoluble carbon- ates which precipitate out, leaving the water soft. Soap with soft water forms a lather. It is difficult or impossible to obtain a lather with soap and hard water (a scum or flaky substance forms), so the use of soda saves the soap and is economical—1 lb. 24 THE PRINCIPLES AND PRACTICE OF NURSING of soda to 200 gallons of water or 30 grains to 1 gallon. Care must be used in the use of the alkali, using only as much as necessary to precipitate the salts; more is very destructive to both the hands and clothing. Alcohol, chloroform, ether, gasoline, kerosene, or benzene are solvents of fats or grease. Oily dirt is insoluble in water._ Alco- hol is frequently used in cleaning glass, in removing stains and for bathing the skin, which it cools, cleanses, hardens, and re- freshes. Kerosene is sometimes used for cleansing bath tubs and hoppers, etc. These solvents are all inflammable and are therefore dangerous; they also evaporate and are costly so care must be taken to keep them away from heat, to keep the cork in the bottle and to avoid any waste in using. 3. Mechanical agents cleanse by rubbing, friction, scouring, scrubbing or by movement—movement of the water or swishing or turning, etc., of the clothes. The agents used are bon-ami (whiting in cake form), whiting (fine pulverized chalk, freed of impurities), sapolio (sand and soap), or silicon. In selecting the agent, consider its effect on the material—does it injure it, scratch, roughen, or deface in any way?—and consider economy in use and in price. 4. Chemical Agents.—The agent used combines chemically with the dirt, etc., and changes it into a soluble substance, easily removed. Agents used are: Ammonia, sodium carbonate (wash- ing soda), potassium carbonate (potash or lye, derived from wood ashes and used in making soft soap), and soap—laundry, toilet, hard, or soft soap. Soap in very early times was quite unknown. Clothes were rubbed and beaten in the running water of streams, as you will remember the sisters of the old Hotel Dieu in Paris used to wash the bedlinen in the Seine to loosen the dirt. Oily dirt required a great deal of rubbing, so much that the clothing was injured. The Ingredients of Soap.—Soap is made by combining fat with a caustic alkali. Fat consists of fatty acids and glycerin, the fatty acid of which combines with the alkali to form a soap. Soda, which makes a hard soap, is the alkali exclusively used in the United States. The fats used may be tallow, grease, cotton- seed oil, cocoanut oil and olive oil, etc. Resin is used in the yellow laundry soap—resin aids in forming a suds and carries off the dirt. If too much resin is used the soap is irritating and de- structive to the hands and fabrics. The cleansing action of soap is the result of:— 1. A Physical Action combined with a Mechanical Action.— A hot, soapy solution loosens, dissolves, and removes the dirt. 2. A Chemical Action.—Soap is an emulsifying agent and the dirt in clothes is largely of an oily nature. The soap causes a dissociation or breaking up of the salts in the water (the caustic soda and fatty acid of the soap separate) setting free the alkali which combines with the fatty or oily substance on the skin or HOSPITAL WARD AS A HOME FOR SICK PEOPLE 25 clothing, thus making more soap so that an increasing lather is formed, and the dirt is removed. 3. Absorbent Agents such as fullers' earth (a kind of clay used by fullers, workers in cloth) which absorbs the oil, blotting paper, or starch. 4. Extraction and Suction by means of the vacuum cleaner and suction tube (used for cleansing plumbing, hoppers, basins, etc.). Care of Specific Materials—such as found in basins, bedpans, etc.—Enamelware.—Wash with warm water and soap. To remove stains use a fine abrasive soap, such as porcella or bon-ami, or use Labarraque's solution. Avoid coarse abrasives as they spoil the enamel. Strong acids and alkalies also destroy the polished surface. Nickel can be kept bright by using hot soapy water. If it be- comes discolored, it can be cleansed by using whiting or a fine abrasive. Porcelain.—For daily cleaning, wash with soap and water or a fine abrasive. For removing stains, use kerosene or tincture of iodin; to remove an iodin stain use alcohol, which dissolves it. Glass.—Wash with soap and hot water. Dry with a soft cloth or a soft chamois-skin. If badly soiled or stained, use whiting; a little ammonia may be used. Too much ammonia will destroy the polished surface of glass. Marble.—Wash with soap and water or bon-ami. If badly stained a fairly strong solution of an alkali may help to remove it. Never use acids on marble or tile. If an acid is spilled, im- mediately neutralize it with an alkali (aqua ammonise or wash- ing soda). Abrasives remove the finish. Aluminum.—Wash with hot water and soap, bon-ami, or whit- ing. Discoloration may be removed with a good metal polish. Never use acids and strong alkalies, and do not scrape. Copper should be washed with soda and hot water to remove the grease. Stains may be removed with vinegar and salt; rinse thoroughly. Silver should be boiled in an aluminum or tin dish in a solu- tion of one tablespoon of sodium bicarbonate and one teaspoonful of salt to a quart of water. Silver and other small articles are, sometimes, carelessly thrown in the garbage. This should be avoided. An inventory of the silver should be kept and checked frequently. THE WARD KITCHEN All the food and supplies, etc., are kept and served from the ward kitchen, which, in turn, receives from the main kitchen and storeroom of the hospital, according to the requisitions sent from the ward. The food and service from the kitchen are ex- tremely important factors for the health and satisfaction of the 26 THE PRINCIPLES AND PRACTICE OF NURSING patient, and the reputation of the hospital depends to a large extent upon it. It is one of the chief items of expense in the hospital, and may be one of the greatest sources of discontent, and of waste in ordering, and in the care, preparation and serving of the food, and also in breakages. It requires very efficient management. Nurses are responsible for the ordering and economy in the use of supplies, for seeing that the steam table is hot, ready to receive and keep hot the food from the main kitchen, and for leaving the kitchen and utensils in order after use. They are also responsible for the care of the refrigerator and for the care of the patients' food sent in for their own use. Nurses should be economical in the use of supplies, in the care of the food, and in the serving. They should serve a satisfying amount, but not more than the patient will desire. They should be careful in the disposal of food left on the trays, in the disposal of food not served, in the use of gas, and in the preparation of food, so that neither food nor utensils may be burned. All breakages, and repairs needed should be reported. Care of Refuse.—There should be a proper receptacle of gal- vanized iron, light, watertight, easily cleaned, readily handled, and with a well-fitting cover. There should be frequent, regular collections with cleaning, airing and sunning. The receptacle may be lined with paper to keep clean, or the refuse may be wrapped in paper. The can should never be overflowing. The cover should always be in place. Care of the Refrigerator.—It must be thoroughly clean at all times. One must be careful not to spill milk or daub butter, etc., and if done to wipe it up immediately. There must always be a sufficient amount of ice, and the doors must be kept closed to maintain the low temperature and to avoid wasting the ice. Avoid overcrowding. Keep things in their proper place—food away from milk, etc. Take particular care of the patients' food —carelessness in labeling, in putting away, in not seeing that the patient receives all that his condition allows, is often a source of great unhappiness and dissatisfaction to the patient. The drain pipe under the refrigerator also should receive careful at- tention to be sure that there is good drainage and that it is kept clean. RELATION OF THE WARD TO THE LINEN ROOM AND LAUNDRY The laundry is one of the most important, most essential, and most expensive parts of the hospital. Clean, fresh linen is essen- tial to the health and comfort of the patients, but a patient can be well cared for, kept clean and comfortable without wasting linen. All linen and blankets, etc., are a very heavy expense to a hospital so that a nurse should be very economical in their use. She should be careful in handling and never use torn linen, but HOSPITAL WARD AS A HOME FOR SICK PEOPLE 27 should send it immediately for repair. This saves time and ex- pense. A nurse to-day is not responsible for washing the linen, but is responsible for its use, wear and tear, and for its condition when sent to the laundry. Damp linen should be dried before sending to the laundry, because if allowed to remain damp for some time, it will mildew. Stains should be removed at once. They can be removed easily at first, but become fixed on stand- ing or when put through the laundry. Linen which has been used for a patient suffering from an infectious disease should be kept in a separate bag and disinfected in order to avoid spreading the disease. Care should be taken also to avoid throwing various articles, such as pillows, instruments, or rubber goods, etc., into the hamper with the soiled clothes. They may be lost or injured and they destroy the machinery, and waste time and materials. Supply to the Wards.—Linen may come direct from the laundry to the wards, or it may all go to the central linen room, from where it is sent to the wards, in response to a requisition, to fill the day's needs. In the wards it is piled on shelves neatly and in order. Care and Use of Linen, etc.—Bedlinen should be changed frequently enough to be fresh, clean and sweet, but no extrav- agant use should be allowed. Where possible, and except in the case of emergencies, there should be definite rules controlling the changing of the bedlinen. Linen may be turned and brushed or shaken; this saves wear and tear. Blankets and linen should never be allowed to drag on the floor. Blankets and spread should be protected from the face and hands by the upper sheet to protect and save washing. Sheets or spreads should be protected by a towel, and in some cases a rubber, in cases of vomiting or hemorrhage; a towel is small and easily changed and washed. The under sheet should be protected by a rubber sheet. Pillows should be protected by a rubber case in bleeding, vomiting or profuse perspiration. Linen and blankets should be protected when in danger of soiling in treatments or giving medications. Blankets are expensive and washing is in- jurious to them. They should be aired, brushed well, shaken and protected. Small spots should be washed out immediately. Removal of Stains from Linen.—Stains may be organic, as in the animal stains from meat, blood, eggs, milk, fat, perspira- tion ; or vegetable and fruit stains from oils, mildew, and various fruits and vegetables. They may be inorganic as from ink, paint, medicines, mineral acids, or alkalies. The agents used to remove them may be:— (1) Solvents.—Water (cold or boiling): Acids such as oxalic acid crystals (1 per cent.), or liquid muriatic acid: Alkalies such as ammonia: Volatile liquids such as alcohol, ether, or chloro- form. (2) Absorbents such as starch, blotting paper, fullers' earth, or magnesia. (3) Chemicals such as soap solution, gasoline or benzine. 28 THE PRINCIPLES AND PRACTICE OF NURSING (4) Bleaches such as Javelle water, borax, sunshine, peroxid of hydrogen, or dilute ammonia. General Rules for the Removal of Stains.—(1) Remove stains as soon as possible to prevent fixation in the fiber. (2) Try the simplest methods first. (3) Cold or tepid water or milk will not fix a stain—hot water will fix some stains, while soaking in cold water will often aid in removal. (4) Soap sets a stain, therefore always remove a stain before the article is washed. (5) When using boiling water, stretch the stained part over a bowl and pour absolutely boiling water with force (kettle held high) through the stain until it disappears. (6) When using an acid, stretch the stained part over a bowl of boiling water, apply the acid with a medicine dropper or old toothbrush, dipping the stain occasionally into the water and again applying the acid. When the stain disappears rinse thoroughly in clear water, then in tepid water containing a little ammonia which will neutralize any acid remaining and prevent any injurious effect. (7) When bleaching by the sunlight, wet the cloth or stain and lay it upon the grass in the direct sunshine. Sunlight bleaches by oxidation in the presence of moisture. Keep the stain moist and leave it on the grass as the process is slow. (8) Peroxid of hydrogen and dilute ammonia also bleach by oxidation and are particularly use- ful for woolens. Use equal parts of fresh peroxid of hydrogen and dilute ammonia (one teaspoonful of ammonia to one pint of water) and moisten the stain until it disappears. (9) When bleaching with Javelle water (which consists of 1 lb. sal soda, ]/4 lb. chlorid of lime, 2 qts. cold water), stretch the article and rub the Javelle water into it; then rinse thoroughly and quickly in clear water and finally in water containing a little ammonia. (10) Volatile liquids such as gasoline, benzine, chloroform or alcohol, etc., should be used in daylight, if possible in the open air, and never near a lamp or fire, as the fumes are very inflam- mable. Do not put any of these agents on a wet cloth as it weakens the action of the liquid and also may leave a stain. (11) Always rinse out acids or bleaches thoroughly. (12) Repeated short applications of chemicals, washing after each in clear wa- ter, are less harmful to fabrics than one long application. Removal of Specific Stains.—Blood.—When fresh or recently dried, soak in cold or tepid water with or without ammonia (am- monia is a solvent of blood); then rub out; when the stain is brown and nearly gone wash out with soap and warm water. If very dry apply peroxid of hydrogen; soak and wash out. When the stain is old, keep it wet with peroxid of hydrogen and ammonia for several hours if necessary. For thick blood and blood on bed ticking, apply a thick paste of starch and water and allow to stand in the sun; when the paste is dry and dis- colored, remove it and apply a fresh paste. Ink.—The method depends upon the character of the ink. The following agents and methods may be used: (1) When very fresh it may sometimes be washed out in HOSPITAL WARD AS A HOME FOR SICK PEOPLE 29 clear water. (2) Soak the stained portion in either sweet or sour milk for several days if necessary; rinse thoroughly and try again if necessary. (3) Apply dilute hydrochloric acid or oxalic acid (one-quarter teaspoonful to a cup of water); rinse thor- oughly. (4) Moisten with salt and lemon juice and lay in the sun. (5) Apply salts of lemon (in powder form); then pour on boiling water. (6) Apply peroxid of hydrogen and dilute am- monia. (7) Apply a few drops of hydrochloric acid or oxalic acid; follow by Javelle water, then boiling water quickly. (8) Red ink may be removed with cold water or water and ammonia or with Javelle water. (9) For indelible ink, if the base is silver nitrate, apply a 10 per cent, solution of potassium cyanid; if the base is an anilin dye, it cannot be removed. Chocolate or Cocoa.—Wash in cold water (first covering with borax helps) ; rinse and then pour boiling water through it. If unsuccessful use a bleaching agent. Coffee.—Pour on boiling water from a height. If unsuccessful use a bleaching agent. Tea.—Rub out in cold water; then pour on boiling water. Glycerin may be used first to soak the stain. Fruit.—Apply warm alcohol to soften and dissolve the stain; then pour on boiling water from a height; or rub with salt be- fore applying the boiling water. If unsuccessful use oxalic acid or a bleaching agent. Milk or Cream.—Wash out with cold water; then soap and tepid water. Vaselin, grease, oils cannot be removed if washed in water. Soak vaselin stains in kerosene before washing—the kerosene evaporates; or wash with turpentine; oil may be absorbed by using blotting paper or powdered chalk. Gasoline may be used for materials that cannot be washed; chloroform or carbona may be used; they are better and there is no danger from flame or explosion. Always rub toward the center; use by daylight and in a draft and have several folds of clean cloth under the stain. Medicines may usually be removed with alcohol. Iodin.—Apply ammonia or chloroform and wash in warm soapy water. Argyrol.—Soak in 5 per cent. (KCN) potassium cyanid. Silver Nitrate.—Apply 10 per cent, solution of potassium cy- anid, or apply bichlorid of mercury, then wash. Picric Acid.—Soak for one minute in a solution of potassium sulphate; then wash with soap and water or apply a paste of magnesium carbonate for an hour or so. Mucus.—Wash in ammonia and water before using soap, or in salt and water. Perspiration.—Use a strong soap solution and let the article lie in the sun. For perspiration under the arm use dilute muriatic acid. Rust.—Lemon juice, salt and sunlight may dissolve it, or dilute 30 THE PRINCIPLES AND PRACTICE OF NURSING hydrochloric acid (this changes the rust to a soluble chlorid), oxalic acid and dilute muriatic acid may be used. Acids.—Sponge with water and a few drops of ammonia. Balsam Peru,—Soak in kerosene or alcohol. £/nne.—Wash with warm water and soap; sponge with alcohol. Mildew—If fresh, it may be removed, but when old, it cannot be removed. Moisten with a strong soap solution; apply a paste of soap or salt and chalk and leave in the strong sunlight for several hours; if unsuccessful use Javelle water or other bleach- ing agent. HOSPITAL PESTS Hospital pests, insects or animals—flies, roaches, bedbugs, mos- quitoes, moths, pediculi, fleas, rats and mice are, as the word "pests" suggests, a great nuisance and menace, and are often de- structive to the hospital. To the patients they are a source of an- noyance, discomfort and alarm, disturbing their rest and sleep, and also a source of danger as they spread disease. They are lovers of filth; they suggest filth and are disgusting and in some cases nauseating especially to a sick patient. It requires the utmost vigilance on the part of everyone to keep the hospital free of them. Flies breed in putrefying and fermenting organic matter. They are attracted by food, garbage and excreta, etc. They multiply very rapidly in warm weather, depositing about 150 eggs at one time. They are offensive and dangerous because their bite is very irritating, very annoying, and a source of great discomfort; they disturb the patient's rest and sleep; they are disgusting to see on food, suggesting filth; they are dangerous because they carry infection on their feet, spreading anthrax, typhoid, cholera, dysen- tery, infantile diarrhea, gangrene, etc. To get rid of them remove all breeding places; leave no food or dirty dishes, etc., where flies can reach; keep garbage tins covered; keep screens on doors and windows and use electric fans; see that there is nothing to attract them; see that the ward, the utensils and patients, especially infants and children, are kept spotlessly clean; place traps and fly paper in places likely to attract, such as on the top of garbage tins or near the light; use the fly swatter vigorously; keep netting over a patient with an infectious disease both for the comfort of the patient, and to prevent the spread of the disease; darken the room as'they tend to follow the light. Roaches are found wherever there is food and moisture—in the kitchens and around the water pipes, etc., and they are apt to get on the trays either when set or if not kept clean. They are more abundant and active at night. They are harmful because they carry filth on their bodies and feet and may carry infection; they are alarming, when on the tray or dishes, to nervous helpless patients with a dislike of HOSPITAL WARD AS A HOME FOR SICK PEOPLE 31 crawling things; they get into the food and are disgusting and nauseating; they destroy the appetite and set up disagreeable associations with that food. To get rid of them have everything absolutely clean; have no food to attract; starve them out; use borax powder, kerosene, sul- phur fumes or exterminator; keep plumbing and building sani- tary. Bedbugs are not always associated with filth, but are found sometimes in new lumber; they are found in cracks, walls, pic- ture moldings, woodwork and beds, etc. They come out at night. They are harmful because their bite is very irritating and poisonous to some people, and may carry certain kinds of dis- eases; they disturb the patient's rest and make sleep impos- sible; they make the patient nervous and restless; they are alarm- ing to some, and have a nauseating odor, and may carry dirt and disease. To prevent bedbugs a building should be insectproof and made of good lumber. In a hospital there are no moldings, pictures, wallpaper or wooden beds, etc., and this helps to keep it free from such pests. Constant vigilance, however, is necessary as both patients and visitors frequently carry them into the wards. The beds should be inspected frequently, kept clean and kero- sene or gasoline should be used frequently on the springs and mattresses. The bugs may be destroyed by pouring boiling water or carbolic over them, or by exposure to sulphur fumes, using two to four pounds to 1,000 cubic feet. For fumigation, to prepare the room, seal all crevices of doors and windows, cover or remove metal articles (the fumes are very injurious to silver, open the drawers and expose all objects. Place the sulphur powder in a flat iron pot, put the pot on bricks in a large basin or tub of water, moisten the sulphur with alcohol and light. Leave for ten or twelve hours; then open the room and air it. Mosquitoes are found in swamps, wells, pools, barrels, gutters, empty cans, damp places, and wherever there is stagnant water necessary for breeding. They fly mostly at night and enter through windows and doors. They are harmful because their bite is painful, very irritating, and poisonous, and they are carriers of disease. Infection may occur from scratching the bite. There are about 400 varieties— the Anopheles spreads malaria, the stegomyia calopus spreads yellow fever. To suppress mosquitoes remove all breeding places. Do not leave anything about containing stagnant water; pour kerosene on pools of water—it floats on the surface and prevents their breeding; stock the ponds with fish which eat the mosquito eggs; put screens on the windows; use electric fans; put netting over patients with malaria or yellow fever; apply spirits of camphor or citronella to the exposed skin. Fleas are found in sandy, warm places, on domestic animals, m carpets and other woolens. 32 THE PRINCIPLES AND PRACTICE OF NURSING They are harmful because they bite, and cause discomfort, and spread disease. Bubonic plague is spread by fleas. To destroy them observe absolute cleanliness; use tincture of green soap or naphtha soap or sulphur fumes. Keep animals out of the hospital and away from sick people. Moths are found in blankets and other woolen goods, and in soiled or dusty garments most frequently. They are prevalent in the spring. They are harmful because they destroy blankets, clothes, furs, etc. To prevent moths keep garments clean, well aired, free from dust, and properly put away with camphor, moth balls, pepper, or wrapped in newspapers (moths dislike the ink) or in tin boxes or moth bags. Examine blankets and clothing carefully before putting them away. Rats and mice are among the worst known pests and cause great financial losses. They are found in every climate, on ships, on the wharf or docks, and in institutions, or any place where there is food. They are great travelers. They are harmful because they destroy food—grain, meat, groceries, and young chickens, etc. They also destroy other ma- terials such as carpets, and undermine the floors and walls of buildings. They may also cause fire by carrying and gnawing matches. They carry dirt and disease. Rats are said to be more or less responsible for cases of human plague and are the most frequent medium by which plague is carried from one local- ity to another. Rats and mice cannot be exterminated but they can be suppressed. All buildings should be ratproof; no food should be left about; everything should be kept clean with noth- ing to attract; they may be destroyed by traps, poison, shooting or. fumigation, or by their natural enemies, dogs and cats. Pediculi are common hospital pests. As they are usually brought in on the head or body of patients, they will be dis- cussed in the chapter dealing with the admission of patients. CHAPTER IV THE HOSPITAL BED: ITS EQUIPMENT AND METHOD OF MAKING The bed is the most important and essential piece of furniture in the ward. It is the most noticeable to one entering the ward and is the one which, perhaps, concerns the patient most, and upon which his comfort largely depends, as he spends most of his time in it. It also perhaps concerns the nurse most, as the greatest part of her work is around, about, and with the bed. Its appearance can make or mar the whole appearance of the ward. The manner in which it is made can make or mar the patient's comfort, and therefore hasten or delay his recovery. The standard hospital bed is a single bed, six feet and six inches long, three feet wide, and twenty-six inches from the floor, made of steel or enameled iron tubing which does not harbor bed- bugs. It is simple, free from decoration, knobs or angles, light, easily moved, convenient to handle, easily cleansed and disin- fected, and possesses strength and durability. The height and size while not always comfortable to the patient are convenient to the nurse and doctor in the care of the patient. The castors are made of hard rubber or hard rubber tire, and are an impor- tant factor in moving the bed without jarring the patient. The springs are usually the national or woven wire which are the most durable and sanitary. Mattresses in hospitals are usually made of stout, blue and white linen ticking (cotton ticking is not so cool or durable), stuffed with horsehair. Curled hair is the best as it can be washed and sterilized if necessary. The weight is about thirty pounds. Hair is more expensive, but wears better and is cheaper in the end than other mattresses. Ostermoor felt and silk floss mattresses are not satisfactory for hospital use because expensive and hard to clean. Horsehair mattresses are firm, cool, more cleanly, hy- gienic, lighter and more practical, and do not soil so readily— horsehair is nonabsorbent. Mattresses must be even and smooth, without lumps or hollows, and must be firm, not loose or sag- ging, but giving a sense of support. Soft mattresses do not give the proper support. The pillows.—There are usually two for each bed—one hard pillow stuffed with hair arid one soft pillow stuffed with feathers (two and a half to three pounds). The hard pillow is used un- der the feather pillow for support to the head and shoulders and sometimes without the feather pillow for coolness in cases of 33 34 THE PRINCIPLES AND PRACTICE OF NURSING fever or profuse perspiration, etc. It is also used for various other purposes such as to support a limb or to retain it in a fixed position. Smaller pillows are also used for special support or comfort. A rubber sheet is used to protect the lower sheet and mattress. It may be cloth faced or double faced. It is narrower than the draw sheet, but is long enough to tuck in well at either side. It must be without thin places or wrinkles. The linen consists of two large sheets, a draw sheet, a spread and two pillow cases. The large sheets should be strong enough to stand pulling tightly and large enough to tuck in well under the mattress all around so that they may be made smooth and tight. The draw sheet, which may be made of single or double cotton, must be wide enough and stout enough to pull tightly and tuck in well under the mattress. It is called a draw sheet because it is easily withdrawn and may be partly withdrawn so as to give the patient a cool place to lie on. The spread should be light and easily laundered—dimity washes and wears well. The pillow slips should fit the pillows loosely. The blankets should be light and warm. They are lighter in proportion to the warmth, depending upon the amount of wool present—a blanket with sixty pounds of wool is the best. As previously mentioned the most scrupulous care must be taken of blankets as the most careful washing shrinks and spoils their appearance and makes them harsh and uneven. Stains should be sponged off at once—first with cold water, then with ivory soap and tepid water, rinsed partially, dried with a clean cloth, then placed in the air and sun. Use old blankets for treatments or when likely to be soiled, or when used next the patient. Never drag blankets on the floor. In hot weather all blankets are in- spected and either put away carefully with moth balls, or sent to the cleaners to be cleaned, or, if badly soiled, to the laundry. Nurses might be more careful if they realized the high cost of equipment. The cost of equipment for one bed was in 1918 as follows:— One bedstead $10.00; a mattress cover $1.00; two pillows $4.00; eight sheets $12.00; six pillow slips $2.00; four blankets $12.00; two spreads $3.00; four nightgowns $4.00; twelve towels $2.00; a rubber sheet $2.00; one bedside table $8.00; two chairs $10.00; a share of the utensils $20.00, making a total of $100.00.1 The cost of equipment has greatly increased since 1918. HOW TO MAKE THE BED FOR A PATIENT The technique used in different hospitals varies, but the prin- ciples are the same in all. They are as follows:—(1) Have everything necessary on hand before beginning. (2) Remember that the bed is made for use, durability, and comfort and that it should have a finished appearance. (3) Place all linen perfectly 1 American Journal of Nursing, 1918. THE HOSPITAL BED 35 straight on the bed, otherwise it will be impossible to make the bed tight and free from wrinkles. The head should be well cov- ered. (4) See that the linen is well tucked in, far enough under the mattress to remain fixed, tight, and free from wrinkles. Tuck in on one side first, tighten on the opposite side. Tighten each article separately. (5) The rubber draw sheet must be smooth and well tucked in, and should extend from the shoulders to be- low the knees. (6) In tightening, do not alter the shape of the mattress, causing it to sag in the middle and do not pull on the corners as this makes them soft, and out of shape, so that it is impossible to make good firm corners. Pull first on the center, then the foot, then the head. (7) Place the cotton draw sheet well up under the shoulders and down to or below the knees to protect the bed, otherwise every movement will loosen and wrin- kle it. The weight of the shoulders holds it in place. The weight of the hips also holds it in place. See that it is well tucked in under the mattress. (8) The upper clothing should be tucked in neatly and well, but not too tightly for comfort. Allow suffi- cient room for turning and for the comfort of the feet; they must not be in a cramped, awkward position, which not only makes them uncomfortable but also makes them numb and cold. (9) The upper sheet, (wrong side up) should be tucked in well at the bottom, but left free at the top with enough to turn over the spread and blanket, to thoroughly protect them. (10) Blan- kets should be far enough up to protect the shoulders well. (11) All the corners should look neat, smooth, and firm. (12) The pillows should be snugly tucked into the corners of the case and should be neat, flat, and smooth. Untidy pillows will spoil the appearance of the bed. (13) Throughout the procedure a nurse should study her movements so as to avoid waste of time and energy. (14) When finished inspect the bed to see whether it measures up to the highest standards. These are the health and comfort of the patient, economy of time, effort, and materials, and a smooth, finished appearance. Then straighten the bed, table and chair. The most finished bed may be spoiled by un- tidy surroundings. When stripping a bed to remake it, place the chairs in position for the bedclothing; remove the pillows; loosen the clothing all around, and remove one article at a time; spread the clothes to air, but do not let them touch the floor; turn the mattress from top to bottom; strip the bed as soon as the patient is up; open the windows and allow the bed and linen to air, if possible, for one half to one hour. THE CARE OF BEDS AND BEDDING In addition to the daily dusting of the beds and care of bed- ding, after the discharge of the patient a more thorough cleans- ing is given than is possible when the patient is in bed. Where possible, it is advisable to move the bed, mattress, pillows and 36 THE PRINCIPLES AND PRACTICE OF NURSING blankets to a balcony where they may be exposed to the sun and air, and plenty of water used without danger of spattering the floor. Otherwise, where necessary, the floor should be protected. The bed should be thoroughly cleansed with warm water and soap. All stains should be removed. Bon-ami may be used if necessary. Mattresses and pillows should be well aired and thor- oughly brushed with a whisk moistened in water or a disinfect- ant solution. Special attention should be given to tufts and bind- ing. Examine carefully for bedbugs. Also, examine for tears and send for repair if necessary. All stains should be removed. Care should be taken to air all sides, but to avoid bending the mattress or pillows at a sharp angle as this is injurious to them. Care should also be taken to avoid placing them on a dirty sur- face, and to protect them from dust or soot, etc. Rubber draw sheets should be thoroughly scrubbed with warm water and soap and thoroughly dried. When not in use they should be rolled on wooden rollers; folding them cracks the rubber and makes it useless. Rubber pillow cases are treated in the same way. After the discharge of a patient suffering from an infectious disease, mattress and pillows, etc., should be disinfected. Mat- tress and pillows may be exposed to hot air, steam under pres- sure, or fumes of formaldehyde. Blankets are usually disin- fected by exposure to fumes of formaldehyde. Rubber sheets may be exposed to formaldehyde fumes or immersed in a two per cent, formalin solution. CHAPTER V THE ADMISSION OF THE NEW PATIENT Types of Patients.—In a hospital which welcomes to its care people of all nations, of all creeds, rich or poor, infants, children or adults, men or women, there will be many types of patients. They will vary widely in their previous experience and education, in disposition and characteristics, in their prejudices and fears, and in the diseases or accidents from which they are suffering. While all must receive equal consideration, all these factors of racial or personal differences call for somewhat different treat- ment. Each demands the greatest sympathy, tact, and under- standing. All our influence should be brought to bear to reassure the patient and his friends in a time of doubt and anxiety. The patient may be alone or accompanied by one or more anxious friends or relatives. They, too, should receive the greatest con- sideration, especially, perhaps, in the case of a mother forced to part with an infant or child, leaving him to the care of strangers. The attitude and behaviour of his relatives have a very marked influence on the comfort of the patient, reacting favorably or unfavorably upon him—calming, soothing and reassuring, or worrying, exciting and making dissatisfied. It is often a trying moment when the friends leave (if the patient is not too ill to care), the patient's impulse being to leave too, if we have not in- spired confidence. Sometimes the patient is the calmer of the two and is made much more at ease if his relatives leave, feeling that he is in good hands. . The Patient's Reception and Welcome.—Let nothing inter- fere with giving him immediate attention. Meet him as though glad to be able to help him, not with indifference, or with a look of if not words, "Oh, dear! here's another case,"—just so much more work. Make him feel that he is expected and that every- thing has been prepared for him. Relieve him of all worry and responsibility. Be alert to notice his general condition and strength—whether able to stand, walk or sit, or whether too weak to talk or hold up his head, and note any symptoms which indi- cate his mental or physical condition. If his friends are not allowed to remain, send them away, but not until they are reas- sured and satisfied that the patient is in good hands and will re- ceive every attention. Take time to listen to and answer ques- tions; satisfv their desire, (which is a very natural one), to see the conditions under which the patient will live. This makes for smooth running, insures a good reputation for the hospital, and 37 38 THE PRINCIPLES AND PRACTICE OF NURSING goes far to aid in the patient's recovery. Nervous "fussy" rela- tives are very trying and disturbing, both to the patient and to the hospital. In many hospitals, patients are admitted first to the Admit- ting or Reception Ward, which is in charge of a headnurse with a staff of pupils, and the admitting or examining doctor. (In some hospitals not provided with an admitting ward, all patients are admitted by the Admitting Office of the Administration De- partment to the main wards at once, where examination, etc., all take place. The patient is first examined by the doctor, his tem- perature, pulse, and respiration are noted, a diagnosis is made and directions given for his admission and care. This ward is provided with facilities for bathing, either tub- or bed-bath, and also with beds for the detention of the patient, if necessary, for further observation. It is also frequently near the x-ray room so that it may be used conveniently in making a more accurate diagnosis, when necessary. The doctor gives directions as to whether the patient is to have a bed- or tub-bath in the Admit- ting Ward, or whether he should go directly to the general ward or not. This depends upon his condition. If an emergency case, or if very ill, he is sent to the main ward and placed in bed im- mediately. If not too ill, every patient on admission is given a complete bath in the Admitting Ward. If he walks in and his condition permits (his temperature not above 100°, or sub- normal, pulse not weak or irregular, or if not suffering from any serious disease such as typhoid, pneumonia, or other respiratory disease) he is given a tub-bath; otherwise a bed-bath is given. He is then well wrapped up and sent to the ward in a wheel- chair or on a stretcher. Admission cards, with the patient's name and address, his age, the name and address of a relative or responsible friend, and the diagnosis, accompany the patient to the ward. If the patient is brought to the ward on a stretcher, place him at once on the bed prepared for him. If the patient walks in, give him a chair. The chair may be beside his own bed (which gives him a more settled feeling, and a feeling of being prepared for), or in an adjoining room, or just within the door, but he should be out of drafts and not inconvenienced by, or in the way of, people passing. When admitted to the ward, notify the doctor on that service that a new patient for him has arrived. Before the doctor comes the patient should be undressed, his temperature, pulse and res- piration taken and recorded, and he should be prepared for exam- ination. It is usually customary also, unless the patient is very ill, to give him the routine admission bath (which every patient receives) before the doctor's arrival. THE ADMISSION BATH Purpose and Value of the Bath.—The admission bath is the first step toward restoring the patient to health. The healing THE ADMISSION OF THE NEW PATIENT 39 powers of water and its beneficial effect on the mind and spirit as well as on the body have long been recognized. Throughout antiquity the purification of the body by bathing has been the symbol of moral purity. Among the Egyptians it was a reli- gious rite, and in the time of Moses bathing was used as a pre- vention of the skin diseases prevalent at that time. In Palestine (and in all the civilized East) wealthy Jews had baths in their houses, and ponds in their gardens. In Greece, where it was the duty of everyone to be healthy, strong, and beautiful, as told in the tales of Homer, the warm bath served for refreshment and entertainment for the guests, even as it does for our guests, the patients. It was also a religious rite, always forming part of the preparation for a sacrifice, for the-reception of oracles or for the marriage rite, etc. In Athens, after the fifth century, B. C, the practice had become so prevalent, the benefits were so uni- versally recognized, that public baths were instituted, as illus- trated in so many writings and in paintings on vases, etc. A small fee was charged. At first in Rome, where health and strength of body were among the virtues most admired, there were public baths in every town and village and private baths in every home, heated by hot-air pipes in the basement. These be- came greatly elaborated, forming one of their chief activities, with gardens, gymnasia, libraries and lecture rooms attached. The remains of these famous Roman baths, sometimes occupying enormous spaces in the heart of cities, may be seen today in Pompeii and Rome. They were abandoned in the sixth century, due to the invasion of the barbaric Northerners, whose rude hab- its and habits of asceticism discouraged the use of the luxurious baths. In the East, among the Mohammedans, they have been retained up to the present, but in Europe, they were long un- known. In the early Christian era, with their ideas of self-sac- rifice and of the evil, sinful flesh, which must be mortified and subdued, the bath was neglected, lack of cleanliness being con- sidered a virtue, because it punished and subdued the flesh. In churches and in monasteries, however, the idea of purification by water was retained, in the religious rite of Baptism, as a sym- bol of moral and spiritual purity. The custom of bathing used in the treatment and prevention of leprosy and other skin diseases was brought back from the East by the Crusaders. In England in the 18th and 19th centuries there was much discussion of the bath in relation to the health. Sea-bathing and bathing in mineral waters were again introduced and public baths were instituted in cities and laws were passed, making their use compulsory. In Germany, Italy, and France the baths were never made compulsory, and even to this day in traveling in the country in Italy and France one finds few bathing facilities. So we see that the bath has always been associated with the prevention of disease and with the preservation of health. To-day, bathing is a matter of habit or custom and the daily 40 THE PRINCIPLES AND PRACTICE OF NURSING bath is considered, by many, almost a necessity, not only for pur- poses of cleanliness but for esthetic reasons. A few patients, however, who are admitted to the hospital, object to the bath. Their reasons vary: Some object because they do not think it necessary and are rather insulted at the suggestion; others think too many baths bad for them, or fear they will catch cold, or they "dont't believe in them anyway and never take more than a sponge bath." Some patients do not object to the bath but from modesty or reserve (fearing exposure), or from a dislike of being waited on, object to someone else bathing them. A nurse must use great tact in overcoming any objections, and must not be intolerant of prejudices, for most of us have prejudices equally unfounded. The patient will soon learn to appreciate the bene- ficial effects of the bath. Its purpose and value may best be understood by a study of the functions of the skin. Functions of the Skin.—1. The skin is an organ of secretion and excretion of waste products in the form of perspiration and sebaceous matter which, if allowed to remain on the skin, would be irritating, form pimples, and cause a tendency to bedsores. In some diseases, the waste products eliminated by the skin are increased so that the need for cleanliness is greater; in others the skin is not functioning properly and it is necessary to stimulate its function by bathing. 2. The skin is the most important means of heat regulation in the body. The body temperature must be kept normal (98.6°) in order to carry on the functions of the body. The blood in cer- tain organs—the muscles, glands and digestive tract, etc.—be- comes heated, by the heat resulting from the chemical processes in the cells, much above what the body needs and this excess heat, if not removed, becomes dangerous and, if allowed to accumulate, will cause death. This heated blood flows through the numerous blood vessels near the surface in the skin, and as it flows it be- comes cooled off by loss of heat through radiation (heat passing to the air) and by evaporation, that is, heat taken from the body to change perspiration (a fluid largely water) into vapor. If this function of heat regulation is interfered with, the body temper- ature is increased, the body functions are greatly disturbed, and death may follow, as illustrated in the legend of the fair, golden- haired Saxon child who was taken to Rome and covered with gold leaf to represent a cherub. In disease, this important func- tion may be interfered with. The skin may be cold and clammy because the circulation is sluggish and there is not enough blood and, therefore, not enough heat in the skin to keep it warm and to vaporize the perspiration; in diseases accompanied by fever, the skin may be hot and dry because the glands are not functioning and heat is not being eliminated by perspiration and evaporation. Bathing will stimulate the functions of the skin so is cooling and refreshing. 3. The skin is an important organ of sensation. It contains many nerve endings and is connected with the brain by many THE ADMISSION OF THE NEW PATIENT 41 pathways. It is extremely sensitive to touch, heat, cold, pressure and pain, etc., and is constantly receiving messages and sending them to the brain, affecting it favorably or unfavorably, and, through the brain, the functions of the whole body. In this way the bath is soothing and refreshing to both the mind and body. Method of Giving the Admission Bath.—If the patient's con- dition permits (when the pulse is strong and regular and his tem- perature is normal), a tub-bath is usually permitted. The nurse should see that the bathroom is warm, free from drafts, that the bath is prepared at the right temperature (100° to 105° F.), and that everything necessary is in readiness. This includes soap, washcloth, face towel, bath towel, nail brush, comb, nightgown, bathrobe, slippers and stockings, etc. Benzene may be used when the dirt resists the soap and water. A nurse must remem- ber that from the moment the patient enters, he or she is under her care, and the nurse must take full responsibility for her. (An orderly is usually responsible for male patients.) Any assistance the patient may need should be given her. She should not be allowed to remain in the bathroom long alone, and never alone with the door locked. The nurse can keep busy close by, within call and, while not constantly in the room with the patient, should be fully aware of her condition while bathing. She may become chilled, faint, or exhausted, or she may accidentally be. severely burned. (A man was recently brought into this hospital who died within a few days as a result of severe burns accidentally received while taking a bath in his own home.) After the bath see that the patient is warmly wrapped and placed immediately in bed. The body of every patient admitted should be carefully ex- amined for rashes, scratches, burns, or bedsores, etc. Such con- ditions, if present, should be reported and charted. A rash may indicate that the patient is suffering from an infectious disease. Scratches may indicate the presence of body pediculi. The patient may claim that burns or bedsores etc. developed in the hospital and this may involve the hospital in a costly lawsuit. The treatment for pediculi will be discussed under the care of the hair. Head pediculi are more commonly met with than body pediculi. A bath in bed is given if a tub-bath is not permitted. For the admission bath, frequently a large amount of soap and water is needed so that extra protection may be required for the bed. In this case a large rubber is used to protect it. As the bed-bath is a more difficult procedure, and used for very ill patients, it is usually given by an older nurse so will be discussed later. CARE OF THE HAIR It is usually customary, on admitting a patient to the hos- pital or ward to include washing the hair in an admission bath. This is always desirable, because it may be weeks before it is 42 THE PRINCIPLES AND PRACTICE OF NURSING possible to wash the hair again and a clean head adds greatly to a patient's comfort. When washing the hair (or when brushing and combing it, if not washed) examine the hair carefully for pediculi. If possible to do so thoroughly without the patient's knowledge, do so; otherwise explain to the patient that, while it is probably an unnecessary precaution in her case, all ward pa- tients must be treated alike. Explain that it is a routine pre- caution that the hospital has found necessary in order to protect her and all the patients who enter, from the possibility of infec- tion. Daily examinations should also be made because of the danger of pediculi being carried in by visitors-and the ease with which the infection spreads. Pediculi, or lice are blood-suckers and parasites which live on the human body. They are found on the hair or on the hairy portions of the body. There are fifty or sixty known species. Those which are sometimes found on patients in the hospital are:— 1. Pediculus capitis, found on the hair and scalp. The eggs or nits are seen as white specks, many on a single hair, and look like dandruff, but cling tenaciously, and cannot be shaken off or removed by combing. 2. Pediculus corporis, the body louse which lives on the cloth- ing and body, causing minute, hemorrhagic specks, and itching about the neck, back, and abdomen; scratches on the body are very suspicious. 3. Pediculus pubis or crablouse, found on parts of the body covered with short hair, especially the pubes. They are harmful and dangerous because they carry filth and are a source of discomfort to the patients, making them nervous and restless. They cause the patient to scratch and these scratches sometimes become infected causing abscesses. They are a source of disease; they are blood-suckers and cause anemia, and they also cause enlarged and infected glands; they are a source of infection, spreading skin diseases, typhus fever and trench fever. They spread rapidly on linen, blankets, bedding, towels, combs, brushes, and other articles. They may be carried by flies. Pediculi may be detected by the habit of scratching, by the presence of scratches and hemorrhagic specks on the body, or they may be seen on the hair, pillows, clothing, or bedding. To prevent or remove pediculi, the clothing, body, and head of each patient must be examined on admission and the head should be examined daily. Particular attention should be given after visiting days as they are frequently carried in by visitors. Note any scratches on the body or habit of scratching. An in- fected patient, his clothing, linen, comb and brush, etc., should be kept isolated as much as possible. In large hospitals, where patients come unprepared with their own combs and brushes, ward combs are used; particular attention is paid to the manner THE ADMISSION OF THE NEW PATIENT 43 of their care and daily disinfection. Brushes for general use should not be permitted. To destroy and remove head pediculi, apply tincture of del- phin, larkspur, delphin and ether, or kerosene to the hair, and wrap the head up closely and securely in a towel. Leave it so for from eight to twelve hours, then wash and fine-comb it. Grease may also be used, as pediculi will not live in it. The eggs or nits are very difficult to destroy. Hot vinegar and soap, or kerosene will help. The hair should be fine-combed daily and fresh applications made if necessary. Kerosene is seldom used in the hospital because it is very irritating and may blister. It is usually diluted with oil and should be used with great care. In bathing the patient if body pediculi are found or suspected the condition should be reported to the doctor who will give the necessary orders. To destroy body pediculi the infected parts of the body are shaved, if necessary. The patient is given a bath in a 1:5000 bichlorid of mercury solution, and blue ointment (a mercurial ointment) is applied to the infected parts. The clothing should be boiled or sterilized by steam under pressure, if it will stand it, or by dry heat, or fumigated with sulphur fumes. The latter is not very effectual. The method of washing the hair may be a tub or bed-sham- poo. The principal points to observe are given in the care of the hair in the morning toilet, Chapter IX. When the patient is allowed a tub-bath on admission, he (or she) is frequently able to wash his own head. The nurse must see that everything is convenient for him, and that he is given any assistance necessary and that he does not become exhausted. RESPECT AND CARE FOR THE PATIENT'S PERSONAL BELONGINGS However poor, ragged or old, dirty or shabby, the patient's clothing may be, they are probably the best- that he has for he will no doubt wear the best he owns unless too sick to care. If they are shabby, he will probably be very sensitive about them, but no word or look should indicate that the nurse is conscious of their poor condition. However shabby they may be, he or she will not like and cannot afford to have them lost or care- lessly handled. They should be treated with the same care as one's own most dainty and costly belongings. Articles lost must be replaced by the hospital, and such carelessness earns for the hospital a bad reputation for carelessness and mismanagement and renders the inmates liable to suspicion—patients have been known to suspect nurses of taking money or valuables. Some articles cannot be replaced, and their loss causes the patient great inconvenience and unhappiness. Lost articles are a constant source of trouble. Wherever possible, it is advisable, if the patient is accompanied 44 THE PRINCIPLES AND PRACTICE OF NURSING by relatives, to have them take the clothes, and especially any valuables, such as papers, jewelry, or money, home at once. A complete itemized list of everything belonging to the patient, retained in the hospital, must be made. Before or immediately after undressing the patient, remove everything from the pockets, make an itemized list, check it over with the patient (if not too sick), have him verify and sign it. Tie the articles up in a sepa- rate package with the list and carefully mark with the patient's name, the name of the ward, the date, and the nurse's signature, and give at once to the headnurse, who will transfer it to the safe kept in the office for that purpose. A receipt is given to the patient or kept by the headnurse. Before putting the clothing away, examine it carefully for ped- iculi, especially in the seams. If articles of clothing are found to be infected or very dirty, it may be necessary to burn them, the hospital supplying others in return. (First explain to the patient if his condition permits.) If not infected, they are neatly folded, listed, wrapped in a bundle, carefully tagged with the date, name of the patient, the ward, and the nurse, and sent to be fumigated or sterilized. The clothing of a patient suffering from an infectious disease is treated with similar care. If pedi- culi are found on the clothing the condition is reported to the doctor who will give orders for the necessary care of the body. The care of body pediculi and infected clothing are discussed under the care of the hair. The provision for the care of clothing varies in the different hospitals. In some cases, equal, if not better care, is given than they would receive in the patient's home. They are cleaned and pressed and all the outer garments—coats and dresses, etc., are hung up carefully on hangers. All clothing is kept under lock and key. This scrupulous care of the clothing must have a very far-reaching effect, contributing to the high standards of per- sonal hygiene set while in the hospital. It is said that the way to keep a man out of the mud is to blacken his shoes. Whatever system is used, an itemized list of all the clothing and valuables should be kept. This list should be signed and verified by the owner, and by the nurse, and should be listed in the clothes book or similar record kept for that purpose. It should also be signed and verified by the headnurse. CHAPTER VI OBSERVATION OF THE SICK THE HABIT OF OBSERVATION ESSENTIAL IN NURSING The habit of keen and accurate observation is one of the most essential factors in nursing. "For it may safely be said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion." x Without it we cannot practice the first essentials in nursing—"the proper use of fresh air, light, warmth, cleanli- ness, quiet," securing comfort, rest and sleep, "and the proper selection and administration of diet." 2 This habit of observing and reporting symptoms is distinctly the responsibility of the nurse; for, during the greater part of the time she is the only one there to observe and report and "what is the nurse there for except to take note of these things?"3 By close observation, a nurse aids the doctor in making a correct diagnosis and in pre- scribing the proper treatment, and frequently is the means of sav- ing the patient's life. This is particularly true in the care of in- fants or children, delirious, unconscious, or very ill patients. This close observation of facts, of cause and effect, lifts nurs- ing far above a mechanical, routine, unintelligent practice, and places it upon a scientific, professional basis. It depends upon knowledge and understanding, upon sympathy and insight, upon experience, and upon a trained eye and ear, sense of smell, and touch. This can only be gained by constant practice for, while the habit of observation can be developed it can only be formed by constant practice in doing. "Stop! Look! Listen!" is a good motto for student nurses. Each time this habit of looking, lis- tening, feeling, or thinking is repeated, strengthens it until the habit of observation is firmly established. Once formed the habit will never fail us. Beginning with the first day on the ward a student nurse should consciously set about forming this essen- tial habit. She should observe first the conditions surrounding the patient—the ventilation, lighting, and general order of the ward. Then in going from bed to bed in dusting, making beds, or performing other duties she should consciously try to observe the appearance and actions of patients in bed and also those 1 Florence Nightingale. 2 Ibid. sIbid. 45 46 THE PRINCIPLES AND PRACTICE OF NURSING who are up and walking around. A good practice is to try to write these observations down later from memory and to check them over with the headnurse. By degrees the student nurse will have learned to observe unconsciously. In this way she will have learned "What to observe—how to observe—what symptoms in- dicate improvement—what the reverse—which are of importance —which are of none—which are the evidence of neglect—and of what kind of neglect."1 This is the practical lesson which every nurse must learn. The last two factors mentioned above vitally concern the nurse, as well as the patient, for it must be remembered that the long and wide experience of Florence Nightingale taught her "that the symptoms or the sufferings generally considered to be inev- itable and incident to the disease are very often not symptoms of the disease at all, but of something quite different"—and that, "if a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, it is generally the fault not of the disease but of the nursing."2 Such symptoms, if they exist and if they are reported, are very misleading and obscure the diag- nosis, for the doctor takes it for granted and has a right to ex- pect that his patient is receiving the best nursing care. The whole purpose of the observation and reporting of symptoms is, not to hinder, but to aid in the correct diagnosis to the end that the patient may be cured. SYMPTOMS AND SIGNS Symptoms may be subjective—those complained of by the patient himself, such as pain, itching, tenderness; or they may be objective—those which may be noted by an observer, such as coughing, difficult breathing, or expectoration. Pain is a symp- tom which may be both subjective and objective; that is, a pa- tient may complain of pain, and the nurse may see by the ex- pression of his face or the position of his body that he is in pain. Physical signs are studied by observation, by percussion (feel- ing with the hand), and by auscultation (listening with or with- out a stethoscope). The number of pulse beats, the body tem- perature, and abnormal sounds made in the heart or lungs are examples of signs. Symptoms, while extremely important, are not always to be relied on. They are often very misleading. As explained pre- viously they may be the result, not of the disease but of neglect and inefficient nursing. They are often misleading in other ways They may be exaggerated by the patient's imagination or mini- mized by his shyness and dislike of giving trouble. Often a patient is unable to describe his symptoms or he may report those having little bearing on his condition and neglect to men- tion those most important. He may be too ill and weary to 1 Florence Nightingale. 2 Ibid. OBSERVATION OF THE SICK 47 concentrate on what the doctor is saying or he may be confused by the questions asked and may give answers which he knows to be misleading. Skilful questioning on the part of the doctor is often necessary to draw from the patient the subjective symp- toms bearing on the case. Again, symptoms may be misleading because they frequently manifest themselves in some part of the body remote or seem- ingly not connected with the seat of the disease. For instance, such symptoms as difficult breathing, or coughing and expec- toration, may be due, not to disease of the lungs but of the heart. A cough may be caused by an abscess in the ear which is causing pressure on a nerve connected with the nerve supplying the lungs and so giving rise to a "reflex cough." Pain is often a very mis- leading symptom because it is often referred or felt in a spot far remote from the seat of the trouble. In the above cases physical signs must be relied on chiefly in making a diagnosis. Symptoms, however, must be listened to and observed very at- tentively, and reported accurately for they are very important to the patient and occupy his attention the most. To be relieved from pain is what the patient desires most, and he will go to the person who will treat him by giving immediate relief from pain, even though that person does not reach the seat of the disease at all. This is largely the secret of the success of quacks, and of the cause of failure among doctors who, although they conscien- tiously seek to treat the real cause of the trouble, ignore and fail to give relief to the annoying symptoms which really drove the patient to him for relief. A patient will often tell the nurse im- portant facts which he "did not like to tell the doctor," "did not want to bother the doctor with," or "did not think it important enough" to tell him. Such symptoms should always be listened to attentively and, if important, reported as far as possible in the words of the patient. Symptoms to Note in the Daily Care of Patients—The Mental Condition.—Note any peculiar behavior, appearance, mannerisms, or ideas of the patient; and any unusual excitement, restlessness, apathy, depression, or emotional disorders which may indicate an abnormal mental condition. The Physical Condition.— The condition of the eyes, whether sensitive to the light (pho- tophobia), sunken or protruding, the lids red, swollen, heavy or drooping; discharge—its character and quantity; puffiness or dark circles under the eyes; the pupils, whether dilated, con- tracted, or unequal. The condition of the nose, difficulty in breathing, or discharge. The condition of the ears, pain, discharge, tenderness behind the ears. The condition of the mouth—In cleaning, note whether the tongue is moist, clean and normal in color, or dry, pale, cracked, or furred, brown or grayish. Note whether it is coated all over or in the center, with the margins bright red. Note the condition 48 THE PRINCIPLES AND PRACTICE OF NURSING of the gums, whether spongy and bleeding or receding, pale or normal in color. Note the teeth, whether true or false, bridge work and fillings, in good condition or decayed. Note the lips, whether pale or healthy in color, blue, dry and cracked or with sordes. Note the condition of the throat, any redness, swelling, patches, ulcerations or discharge, any hoarseness, or difficulty in speaking, any external enlargement, swelling or tenderness to the touch. Note the odor of the breath, which may be heavy, foul or fetid from decayed, ulcerated teeth, from chronic catarrh, from diseased tonsils, from the stomach or intestines, or from abscess or gangrene of the lungs. Sometimes the odor of alcohol or of certain drugs, or an odor characteristic of certain diseases, such as a sweetish odor in diabetes, may be detected. The expression of the face, whether pinched and anxious, dull and apathetic, excited or nervous, or indicating severe pain. Note the color of the face, whether pale, flushed, cyanotic, jaundiced or any other abnormal color. The condition of the body, whether poorly or well nourished, emaciated or fat, bones prominent or well padded (danger of bedsores) the muscles firm or flabby, the skin loose and wrinkled, or firm and smooth. Note particularly the hand; note whether emaciated or fat, hot or cold, moist or dry, pale, flushed or cyan- otic. Note the movements of the hands, whether trembling, rest- less or listless and inactive. The hand is often a more accurate index of the patient's condition than the face. The condition of the skin, the presence of itching, scratches, a rash, abrasions, sores, ulcers or wounds; note whether dry, hot and feverish, warm or cold and clammy or sensitive to cold; whether thin, red or tender and apt to become sore—examine particularly the buttocks, over prominent bones, and between rolls of flesh. Note any swelling of glands in the neck, axilla, breast or groin, also any growths, or any abnormally tender spots. Note any coughing and expectoration. The condition of the abdomen, whether distended (as by gas or fluid) or enlarged by a tumor, or tender to the touch or pres- sure. The condition of the extremities, the gait of the patient, diffi- culty in walking, shuffling or dragging of the feet, loss of motion, enlarged, swollen, tender joints, the hands or ankles puffy and swollen. Note any discharge from the vagina and any lack of control of the bladder or rectum. Note the loss of function of any of the special senses. Note the position of the patient, whether it is difficult to turn difficult to breathe lying down, or when lying on one side etc. The general condition—Note whether the patient is gaining or losing in strength; note whether he is more or less tired by exertion and whether he feels like doing things for himself or whether he is too weak and listless to make the effort. Note whether he is eating well or not, whether his appetite is im- OBSERVATION OF THE SICK 49 proving or not, and whether he expresses any desire for food or other things which formerly gave pleasure. Note whether he enjoys visitors, conversation or reading or whether he is easily tired. Note whether he is sleeping well or not and note the char- acter of the sleep and the time and duration of the sleep. Any change indicating either improvement or the reverse should be noted and reported. CHAPTER VII HOW TO MAKE A HELPLESS PATIENT COMFORTABLE METHODS OF MOVING, TURNING, LIFTING, SUPPORTING, AND PERSONAL CARE IN RELATION TO COMFORT From the time the patient is duly admitted to the ward, to make him as comfortable as possible in mind and body is one of the first and most important factors in the nursing care. His recovery will depend to a large extent upon his comfort, and this will depend almost entirely upon the nursing care. In order to make him comfortable a nurse must understand what constitutes comfort and must become skilled in moving, turning, lifting and supporting, and in other ways of making patients comfortable. What Constitutes Comfort.—"To comfort" as defined in the dictionary means to strengthen, support, invigorate, refresh, glad- den, cheer, and to give relief from pain and trouble. It means a mind at ease, with congenial occupation and diversion, and free from care or worry. It means a body free from pain, hunger, cold and fatigue, etc. Th'e Importance of Comfort in the Care of the Sick.— Physical rest and relaxation conserve the energy and build up the resistance to disease. It is absolutely essential to the re- covery of the patient and to the success of many therapeutic measures. Happiness and contentment also promote recovery. They mean mental rest and relaxation and this puts the body in the best con- dition to conserve its energy and to resist disease. When the mind is depressed or overstimulated by painful emotions the body cannot function properly. Someone has said that such emotions as excitement, anger, fear, and worry are like strong, hypodermic injections of highly poisonous drugs. They have a very injurious effect on the body and interfere with digestion, the secretion of glands, the action of the heart, circulation, and respiration, and all the other functions of the body. Happiness and contentment have also a definite social value whether the patient is in a private home or in the hospital. They make things run much more smoothly and this in itself aids in the patient's recovery. They also add to the good reputation of both the nurse and the hospital. The ability to make her patient comfortable, happy, and contented is the chief mark of a good 50 MAKING A HELPLESS PATIENT COMFORTABLE 51 nurse and is essential to the success of every treatment. After every treatment or procedure a nurse should ask herself, "Is my patient comfortable?" Causes of Discomfort in Illness.-—Physical Causes may be:— 1. The Position of the Patient.—The discomfort may be due to cramped, strained, and tired muscles from lack of support, slipping down in bed, straining to reach the table or bell, pillows disarranged or not properly adjusted, or it may be from lying too long in one position. 2. Weight and Pressure on Sensitive Parts.—This may be the patient's own weight: The weight of his arms resting on his chest or abdomen, the weight of his limbs crossed and resting on each other when he is too weak to move, the weight of the body and pressure on the buttocks when sitting up, the weight of the head on the chest when not properly supported, the weight of the body lying on one arm, the weight and pressure on prominent bones, the weight of the bedclothes on the chest, abdomen or painful ex- tremities as in burns, ulcers, sprains, fractures, and rheumatic joints, and it may be pressure from casts, splints, or tight band- ages. 3. Friction, rubbing and chafing from restlessness, constant turning, friction of the bedclothes, or moisture, crumbs or wrinkles in the bed. 4. Extremes of Temperature.—Discomfort from heat may be due to a high body temperature, or to the heat of the surrounding air or to too many bedclothes. Discomfort from cold may re- sult from lack of heat production in the body, or poor circula- tion, or from cold air, drafts and too few bedclothes. Mois- ture in the atmosphere, or on the body (perspiration), and damp clothing all cause chilling and discomfort. 5. Interference with Bodily Functions.—Sleeplessness, or an irregular, broken sleep, loss of appetite, indigestion, constipation, and weakness from unused, weak and flabby muscles resulting from lack of fresh air and exercise, all cause discomfort. 6. Lack of cleanliness, irritation of the skin, itching, aches and pains are frequent sources of discomfort. 7. Unskilful handling, and sudden, jerky, clumsy, noisy, start- ling, and unsteady movements are among the common sources of discomfort. Mental Causes of Discomfort may be:—Strangeness, home- sickness, worry about finances and home conditions; shyness, sensitiveness, apprehension and fear of pain, suspense, uncer- tainty, monotony, restriction of personal freedom, exposure, lack of privacy, and being treated as a "case" or as a child and not as a rational human being; too much light and noise, pain and distress of others, odors, vomiting, and complainings, lack of system, disorder, delays, confusion, and mismanagement. Lack of interests is a common cause of discomfort. The sudden cut- ting off of normal, active mental occupations and varied inter- ests leaves a blank and forces the mind to feed upon itself, for 52 THE PRINCIPLES AND PRACTICE OF NURSING the. mind is so constructed that it must pay attention to some- thing. A mind feeding upon itself is not a healthy mind, and soon becomes depressed, morbid, and self-centered and the pa- tient becomes interested only in what directly concerns himself. He is apt to worry and complain about his meals, his dressings, and general care, and to feel that he is not receiving enough at- tention. Means of Securing Mental Comfort.—We should try to make patients feel at home, or at least that they are among friends, and should try to relieve them of any worry regarding their home, by placing them under the care of the Social Service Depart- ment. We should try to inspire confidence in the hospital and staff, making them feel happy and contented, and confident that the hospital, doctors, and nurses are quite competent to look after them. Patients should never have to worry about their care— that is what nurses are there for. This is one of the first prin- ciples laid down by Florence Nightingale who observes:—"It is commonly supposed that the nurse is there to spare the patient from making physical exertion for himself—I would rather say that she ought to be there to spare him from taking thought for himself. And I am quite sure that if the patient were spared all thought for himself, and not spared all physical exertion, he would be infinitely the gainer." "In the hospital it is the re- lief from all anxiety, afforded by the rules of a well-regulated institution, which has often such a beneficial effect upon the patient." x We should never trouble the patient with our diffi- culties or complaints and should refrain from discussing such matters as mismanagement or lack of experience on the part of his nurse, lack of time or of nurses, or of supplies. We should never allow him to feel that there are difficulties to interfere with his proper care. A nurse should not look to the patient for sym- pathy because of hard work, long hours, or criticisms for faults found in her work. She should make him feel that she does things for him because they will help him and because she wants to do them, not because she is told to do them. The surest way of making patients happy and contented is by being so our- selves. A nurse should not be so occupied with the appearance of her work, irritated or afraid of criticism if it is upset, that she makes the patient afraid to turn or relax properly. But a cer- tain amount of wholesome fear of criticism for untidiness or lack of cleanliness is good for both patient and nurse. A nurse should not make the patient feel that she has so much to do that he is afraid to ask for necessities, such as a bedpan, until the need or desire is past. Patients are often too shy and sensitive to risk displeasure and it is true that some unscrupu- lous nurses take advantage of this. We must remember that the patient is a human being with needs and feelings like ourselves. We should treat him and his friends as we would like our mother or sister to be treated, or as we see the patient prefers. For we 1 Florence Nightingale. MAKING A HELPLESS PATIENT COMFORTABLE 53 must remember, that people differ in the way they like to be treated and in what they consider attention or neglect. Some are sensitive and reserved, like to be left alone, not "fussed over," and are embarrassed and irritated by too much attention. Others like constant attention, like to be pitied and never left alone— think you are heartless if you leave them and are even jealous of attention to others. We must consider and indulge the feelings of each where possible without overindulgence or neglect of others. A nurse should try not to distress a patient by forgetting and making him repeat his requests, or likes and dislikes. This is very tiring and disappointing. She should not forget to post his letters, for instance, whether important or unimportant; this for- getfulness may keep him awake for hours. She should not make a sensitive patient request assistance a nurse should see for her- self is needed; for instance, placing a bedside table and drawer within easy reach, placing the tray with food conveniently, lifting, turning, changing his position in bed, shaking and turning his pillows, replacing soiled damp gown or bedding for clean, dry linen, protecting from drafts, pulling down the shade to pre- vent light from shining in his eyes, not allowing him to sit up too long or until fatigued, protecting with a screen from distress- ing sights around him, or giving the bedpan at regular intervals or when desired, etc. Some patients will ask for what they want; others are too shy, indifferent or sensitive. They "hate to give trouble" while others expect attention without asking for it; that is, they expect a nurse to know her business. In nursing one must avoid an air of mystery but one must also avoid telling the patient by word or look his condition, temperature, pulse, or respiration, or what medicines, etc., he is getting. And while it is necessary to cheer a patient one must not do so by raising false hopes, by telling, him untruths, or by making light of his illness. It is natural for the patient to ask such questions, and the nurse should show tact and understanding in dealing with them. There will be no difficulty if she merely informs her patient that the doctor is the only one who answers such questions, but she should dispel all ungrounded fear regarding treatments ordered by the doctor. "Do, you who are about the sick, try and give them pleasure, remember to tell them what will do so." "A sick person does so enjoy hearing good news:—for instance, of a love and court- ship, while in progress to a good ending." "A sick person also intensely enjoys hearing of any material good, any positive suc- cess of the right." "Do . . . tell him of one benevolent act which has really succeeded practically—it is like a day's health to him." "They don't want you to be lachrymose and whining with them, they like you to be fresh and active and interested, but they can- not bear absence of mind, and they are so tired of the advice and preaching they receive from everybody, no matter whom it is, they see." 1 1 Florence Nightingale. 54 THE PRINCIPLES AND PRACTICE OF NURSING "There is no better society than babies and sick people for one another." "An infant laid upon the sick bed will do the sick per- son, thus suffering, more good than all your logic. A piece of good news will do the same." 1 This effect of a baby on the sick is sometimes seen in a surgical ward when a mother has undergone an operation and her baby is brought to her to be nursed. The whole ward seems stirred and brightened to a cheerful, tender, kindly feeling and each pa- tient strains to see or hear all about the baby. Even the most seriously ill and exhausted are aroused to a tender interest and to new hopes. Even if the baby cries it does not seem to disturb or annoy but causes only a feeling of solicitude for its comfort and happiness. Never tell or read a story which will either depress or stimu- late and excite, and which tends to make the patient argue, or which in any way taxes his mind. One must remember the pa- tient is always below par mentally as well as physically, and soon tires with talking or reading. The only object in talking or reading to a patient is to divert and give him something pleasant to dwell upon, and not something which will excite or set his imagination working and keep him awake for hours. One should never attempt to read or tell funny things to a very sick patient —how can anything seem funny to the very sick? It only sounds heartless. A nurse should try to relieve the monotony which is one of the main sufferings of illness. "The craving for variety in the starv- ing eye, is just as desperate as that of food in the starving stom- ach, and tempts the famishing creature in either case to steal for its satisfaction." The love of beauty, of variety and color, the longing to escape from the confinement of four walls, to see out of the windows, to see the trees, green grass or water, to see young, playful things, and to be able to gaze off into the distance becomes almost insupportable. There is a great sameness in the hospital from day to day. The very system and routine upon which its efficiency depends make it so. Even the nurses' uni- forms, while generally admired because fresh, neat, and clean, seem to get monotonous,—I have heard patients say they thought it would be "nice" for the patients, if the nurses did not all wear the same, but wore different dresses of different colors and made differently. Whenever it is possible, monotony should be re- lieved by removing the patient to the balcony, to the lawn, or to the window, or by showing them beautiful pictures of trees and flowers, of the sun and water, or of children—something to re- fresh and rest the mind. When the patient is well enough, she should have a little manual occupation—knitting, sewing, making supplies or playing games, etc. The value of manual occupation^ of keeping the fingers and the mind occupied, has been well dem- onstrated in the late war in restoring the sick soldiers to health, both mentally and physically. Nurses should try to remove the 1 Florence Nightingale, MAKING A HELPLESS PATIENT COMFORTABLE 55 feeling of strangeness. We know ourselves, for instance, how dif- ficult it is to sleep in a strange bed, or to adjust ourselves to dif- ferent surroundings or people, and this the patient is in no con- dition to do. A nurse should see the patient has as much pri- vacy as possible by screening the bed when the patient is very ill or when she desires to rest or sleep, and for all treatments. Some patients are sensitive and do not like being observed when taking medicine, getting dressed, trying to walk, getting up or back to bed, trying their strength by walking, etc. A nurse will often be surprised to find these done on her return, and will won- der why the patient did not wait for her to help him. Noise is most wearing and distressing to the sick. Nurses should avoid sudden, sharp noises, rattling windows, and dishes, etc., rustling uniforms, creaking shoes, flapping of blinds and cur- tains. They should avoid whispering in the room or outside the door and should avoid a long conversation in the corridor when the patient is expecting his nurse each moment to enter—I have known a nerve specialist to keep the patient waiting in this way intentionally when he wished to see the patient at her worst. A nurse should avoid a conversation in the room with others in which the patient is not interested, or to which mind and body are too weak to attend. All unnecessary noise is cruel to the patient. Nurses should try not to forget things—this means open- ing and closing doors too often; they should never walk on tip- toe—this makes the patient self-conscious and is injurious. One should avoid hurry and bustle, but be efficient and quick in carry- ing out requests. The patient should not be startled by a sudden entrance, by a sudden announcement, by someone speaking sud- denly, unexpectedly, from behind, from a distance, or when he is otherwise occupied. "Don't let the patient be wearily waiting for when you will be out of the room or when you will be in it." A nurse should never show doubt, hesitation, uncertainty or in- decision in her movements or speech and should remember that she is there to plan, to remember, to decide for the patient, and to relieve him of all responsibility. The effect of visitors depends upon the visitor and the patient's condition, and can only be judged after the visitor has gone. It is most important to see that the right visitors are admitted. They should be given a chair; one should never stand while con- versing with a patient or seem in a hurry to get away. The chair should be placed conveniently and near the bed, where the pa- tient can hear and see without straining. The patient should be in a comfortable position for conversing. The visitor should be warned against leaning against, sitting upon, placing articles upon, shaking, or striking the bed for the patient feels the jar all through. Patients should be allowed as much privacy as pos- sible when friends are present, and all treatments should be ar- ranged, if possible, so as not to interfere. Visitors should be prevented from giving the patient any food, etc., that he should not have. He must not be allowed too many visitors and they 56 THE PRINCIPLES AND PRACTICE OF NURSING must not be allowed to tax the patient's strength by staying too We must remember that what to the well would be a trifling annoyance soon forgotten may be to the sick a source of pro- longed suffering, delaying recovery, or hastening death. Means of Securing Physical Comfort:— 1. By Changing the Position of the Patient.—We must remember that even the most comfortable position will become unbearable if the patient is forced to remain in it for any length of time. The patient's position, whenever his condition will per- mit, should be changed frequently. The usual position in bed is the dorsal recumbent, that is, lying on the back. When m this position, the pillows should be arranged so as to support the weight of the shoulders and head, without pushing them forward on the chest: Such a position besides being strained and un- comfortable, producing a cramp in the neck, also interferes with breathing. When the patient is lying on his back the strain on the muscles of the back (particularly in the hollow or small of the back, as the weight of the body rests on the shoulders and hips owing to the curves of the spine) and the strain on the abdominal muscles from the pull and weight of the outstretched limbs are very severe and painful and soon become unbearable. Again the strain in the hollow of the knee, due to the pull on the tendons when the leg is outstretched, may become agonizing. The strain on the muscles of the back may be relieved by supporting it, filling in the hollows with small pillows, small pads, or a hot- water bottle partially filled with warm water. Patients who are strong enough will support this part with their hands, a book or pillow from under their head, or by stuffing the bedclothes or any- thing in the "small" of the back to relieve the intolerable strain. The strain on the abdominal muscles and tendons under the knees may be relieved by flexing the thighs and knees and supporting them with a bolster, a folded pillow, or a special device. All hol- low places should be filled in. One of the best ways, and most delightful to the patient, of relieving strain and fatigue of the muscles due to position is by stimulation of the circulation by massage or rubbing the back and legs with alcohol. The fatigue is due to poor circulation—the accumulation of waste products and lack of fresh food supplies. The massage moves the waste blood along and fresh blood takes its place. When lying on the back the weight of the patient tends to drag him down in bed, making his position uncomfortable. His pillows should be shaken and straightened and the patient lifted back into a comfortable position. To lift up in bed, when at all advisable, two nurses should lift the patient. They may stand on the same side or on opposite sides. One nurse should support the head, shoulders and back by placing one arm across the back to the opposite axilla, and, with her free hand, lifting and arranging the patient's head so that it will rest comfortably on her arm, the other arm being then placed across the small of the back. The second nurse places MAKING A HELPLESS PATIENT COMFORTABLE 57 an arm across the back, the other arm under the thighs. Flex the patient's knees, have him place his feet firmly on the bed. and press when being lifted—both nurses must lift together. When it is not necessary to support the patient's head, the nurses may clasp hands behind the patient's shoulders and beneath the thighs and, lifting him from the bed, gently swing him into po- sition. The patient may place an arm around the shoulders of each nurse for support. Have him press with his feet on the bed as before and all lift together. To Turn on One Side.—Again, the back and legs, etc., may be relieved by turning the patient on her side. In doing so, see that the head, shoulders and hips are properly adjusted, and that the neck, shoulder and arm are not cramped. Also see that the weight of the body is not on the arm, and that the legs are flexed at the thigh and knees. The weight of the upper leg should not be on the lower—it should be flexed a little more, with a pad or pillow placed between them. The back should be sup- ported its whole length with pillows so that the patient can com- fortably relax. A small pillow in front of the abdomen for the patient to lean against, with slight pressure, gives great relief and comfort, especially when the patient is suffering pain from gas in the stomach or intestines. See that the patient, when turned, is not too near the edge of the bed—she might fall out, especially when asleep. Even if there is no danger, it may be alarming to a nervous patient. In turning, moving and lifting, etc., a weak and helpless pa- tient should be protected from all unnecessary exertion. To turn such a patient toward you, place one arm obliquely across his back extending from the far shoulder to the side nearest you and the other arm in the same way around his hips; then lift and draw him slightly backward and at the same time turn him gently and smoothly toward you. Then make the necessary adjustments as suggested above. To turn him from you, slip one arm from the side nearest you under his back to the far shoulder, and place the other around the hips in the same way. Then lift and draw his far side slightly toward you so that he is gradually turned away from you. When patients can turn themselves without injury, it is bet- ter to allow them to do so. For instance, when movement causes pain as after an abdominal operation, the patient may prefer to turn himself and can do so with greater ease and comfort. He will turn very slowly, first one part of the body, then another, instinctively making those adjustments which cause the least pain. A nurse may gather many useful hints by intelligently ob- serving how such a patient turns and adjusts himself. It is good for patients to help themselves when their condition permits. To Sit Up in Bed.—Sometimes at the beginning of convales- cence, when the strength is gradually returning, the patient is allowed to sit up for a short time only. Again, the patient may be obliged to sit up night and day because of a difficulty in 58 THE PRINCIPLES AND PRACTICE OF NURSING breathing, as in certain diseases of the heart and with congestion of the lungs. This condition is called orthopnea. When sitting up, the pressure of the abdominal organs does not encroach upon and embarrass the action of the heart and lungs as when lying down. The diaphragm is more easily depressed and more room is allowed for chest expansion. Comfort in this position may be secured with extra pillows, with a backrest (securely tied to the head of the bed) and pillows, or with a Gatch frame—an adjustable frame by which the patient may be supported in a sitting position with the thighs and knees flexed and supported at any angle desired. When the patient is still weak and is allowed up for a short time only, it is important to avoid all effort, strain and exhaustion. There must be no jerking or pull- ing in the effort to lift up so that the poor patient becomes exhausted in the effort and can't enjoy the treat, long looked for- ward to, of a change in position, or being able to look around, or out of the window, etc. Have a second nurse assist you if neces- sary. Have everything necessary at hand and in a convenient position. Support the patient throughout the adjustment of the pillows or backrest—it must be done quickly and expeditiously. See that the shoulders are protected with a nightingale or chest protector. The patient's resistance is lowered and the exposed neck, chest and shoulders with their large blood vessels, are very sensitive to cold, or to a change in the temperature, and, if exposed, may chill the whole body and further lower his resis- tance. The number of pillows required varies with the position, the patient's condition, the means of support, and the length of time the patient will be sitting up. If only during meals, the two pillows on the bed alone may be arranged to elevate sufficiently. The pillows may be arranged upright, crosswise, or both. In all cases see that the head, neck, back, and arms are properly sup- ported with no "crook" in the neck, no hollow in the small of the back, the head not thrown forward on the chest, the shoulders not forward with rounded back and hollow chest, making it difficult to breathe: The shoulders must have room to fall back, and the chest room for expansion. There is nothing more distressing to the patient and the observant onlooker if this is disregarded. Also the arms should not hang unsupported with their weight dragging on the shoulders and chest; neither should they be allowed to rest across the chest or abdomen: Their weight be- comes extremely oppressive and unbearable. Arrange the pillows so as to support the full length, not forgetting the wrist and hand. Especially support the arms when weak or edematous. Flex the thighs and knees; support them with a bolster, pillows (tied to the head of the bed), or other device under the knees to prevent the patient from slipping down in bed. Remember that when the patient is sitting up for the first time or when weak, this change of position is a great tax on his strength. The heart and circulation may not have time to adjust themselves to the change, so that sufficient blood does not circu- MAKING A HELPLESS PATIENT COMFORTABLE 59 late through the brain to maintain consciousness, and the patient may faint. Do not leave him alone for many minutes. Take the pulse before and shortly after the patient is up, and note his color and facial expression. Don't allow the patient to become pale, weary, fatigued, and exhausted; don't wait for the patient to plead to be "let down"; don't use up his last ounce of strength (lowering him again is in itself an exertion and a strain), but leave him with a feeling of refreshment and pleasure. Shake and turn his pillows, massage his back and make him comfortable. A hot drink will help to revive him if feeling weak. _ The Use of a Bedside Table in Dyspnea.—Patients obliged to sit up in order to breathe with any comfort, usually breathe more easily when leaning forward. In this position the pressure of the mattress against the posterior chest which interferes with the expansion of the lungs in the posterior chest is relieved and the chest can expand more freely. It removes the obstruction, gives energy, and gives more air to the smothering patient. The slight- est pressure may interfere—the weight of bedclothes, of a mus- tard paste, poultice, hand or arm. Pressure which would be insignificant in health may seem like a mountain, and every effort to breathe like trying to move it, with a tremendous strain on the muscles and strength. To support the patient and allow him to relax, place a tray with a soft pillow on it in front of the patient for him to lean upon and press pillows against the lower back for support. Guard against chilling—the lungs are already congested and the chest sensitive to cold. These patients are always in a critical condition—watch them carefully. When the patient is in the usual sitting position, the full weight rests on the buttocks and end of the spine. Great care must be taken to relieve the pressure by the use of rubber rings, etc., and to keep the part in good condition by keeping it clean and dry and stimulating the circulation by massage in order to prevent pres- sure sores. To Sit Up in a Chair.—As the patient's strength increases she may be allowed to sit up in a chair—to strengthen the muscles and gradually regain strength, to get used to the sitting position without feeling faint, and to provide a change of position. It is a treat for the patient to get out of bed, to feel the feet hanging down, and resting on the floor for even a few moments. This allows the bed to be aired, the mattress turned, and the bed remade. See that the chair is comfortable, in good repair, protected with cushions or pillows, and placed conveniently (at right angles to the bed) for lifting, or helping the patient in and out, so that neither the patient nor the nurse will need to take any extra steps. See that the patient is well protected with dressing gown, stock- ings, slippers, and blankets to suit the weather and his condition. Allow no exposure in dressing. In lifting him into the chair do so gently and gradually, without jerking or straining. In order 60 THE PRINCIPLES AND PRACTICE OF NURSING to do so have someone to assist you, both to avoid unnecessary strain upon yourself or the patient, and to give the patient a feeling of security. Otherwise both patient and nurse may be breathless and exhausted after the effort. When patients have been lying down for a long time and their position is changed, as in sitting up in bed, or in a chair, or in standing, it takes time for the circulation to adjust itself, for position has a great deal to do with the supply of blood in the brain. People instinctively assume the position not only which gives them the greatest com- fort, but which either soothes or makes the brain more active. For instance, when we wish to think we instinctively do some- thing to increase the blood supply in the brain. Some walk about so that the heart and circulation are stimulated. Others do their best thinking when lying down, for instance, after they have gone to bed, and say they wish they could remember in the morning all the poetry or wise things they thought of before going to sleep. Again when the brain has been active (increased blood circulating in it) many cannot sleep unless the head is elevated by two or more pillows:—Everyone has, no doubt, had the annoying experience of being obliged to sit up in company when they could hardly keep their eyes open, and yet when at last in bed have found it impossible to sleep for hours. This is due to the effect of position on the circulation of the brain. A sudden change in position which lessens the blood supply in the brain may cause the patient to faint. Raising the patient's head or body suddenly, then, may cause her to faint because the blood remains in the body, leaving the brain anemic. Dr. Brunton relates that in Paris, before the use of chloroform as a means of producing anesthesia, or loss of con- sciousness, it was customary to suddenly raise the patient from the recumbent position, the head being raised so quickly the blood had not time to follow it, so that the brain became very anemic and loss of consciousness resulted. Another very serious condi- tion which may develop when the patient is allowed to sit up or move about for the first time is the formation of an embolus. During an operation many blood vessels are cut. The bleeding is checked by the formation of clots. These clots may be in blood vessels where they do not obstruct the flow of blood and so do no harm. But when the patient sits up the heart must work much harder, and the pressure of blood is much greater. A clot may be dislodged and carried along to a vessel in the lungs, the brain, or walls of the heart where it completely obstructs the circulation and supply of blood to the tissues. This may mean instant death. A clot of blood in a vessel is called a thrombus. When it is set in motion and obstructs an important blood vessel it is called an embolus. The condition is called embolism. The patient may die, for instance, from pulmonary embolism. Lift the patient then with great care. Remember that the muscles are very weak from lying in bed. Do not allow him to stand, or if so, only for a few moments, for standing is the most MAKING A HELPLESS PATIENT COMFORTABLE 61 trying position. When in the chair see that he is well supported, with no hollows in the back, that the head is comfortable, that the feet and legs are snugly and neatly wrapped in the blanket, that a_ foot-rest is provided to keep the feet from the floor where there is apt to be drafts; that a hot water bottle is provided for the feet if necessary; that the arms are free (if not too cold) and provided with arm-rests, that the chest is protected; that the patient is not sitting in a draft or in the way of people passing, and that the chair is conveniently placed near the table or near the window, etc. If the legs are edematous or ulcerated, or the joints are painful, keep the limbs elevated. Count the pulse before and after the patient is in the chair. Watch for the slightest signs of fatigue. Don't wait until the patient is exhausted before putting him back to bed so that he is "all of a tremble," so weak that he is "ready to cry" with fatigue or too tired to eat or too nervous and exhausted to sleep. What should have been a treat and benefit to the patient may set him back because of a careless, unobservant, unintelligent nurse. A patient is seldom allowed up for more than one-half hour for the first time, and even less than that if fatigued. While the patient is in the chair, the mattress may be turned and the bed aired and re-made, or the clothes may be straightened and made ready for the return of the patient. To put the patient back to bed, observe the same care as when lifting into the chair. Undress him without exposure; make him thoroughly comfortable and allow him to rest quiet and undis- turbed. Chart the rate and character of the pulse, the time allowed in the chair, and the effect on the patient. To Lift a Helpless Patient.—One nurse alone should never try to lift an adult because of the danger and strain on both nurse and patient. Few patients have confidence in the strength of a nurse, and while they may laugh during the effort, they may really be excited and alarmed and this is injurious. Two nurses at least (or a nurse and orderly) should lift together and when carrying should keep step to avoid sudden, jerky, jolting move- ments. Hold the patient securely, not sagging in the middle of the back and not as though he might fall any moment. One nurse should support the head and shoulders (by placing one arm across the back, the hand extended to the axilla and the patient's head resting comfortably on your arm) and the back, while the second nurse supports the back and the limbs, one arm being placed under the back, the second under the flexed thighs and knees. When lifting up in bed both nurses may stand on the same side or on opposite sides; when lifting to a chair, both stand on the same side. When lifting save the muscles of your back and allow the shoulders to bear the weight. Bend the knees slightly, but do not bend the back—bend from the hips. Always move a patient to the side of the bed before attempting to lift him from it. While strength is necessary in lifting easily, it is largely a mat- 62 THE PRINCIPLES AND PRACTICE OF NURSING ter of skill; that is, knowing how to use your muscles to the best advantage. To Turn the Mattress with the Patient in Bed.—When the patient is in bed for a long time the mattress may become uneven or uncomfortable so that it becomes necessary to turn it, or to change it, or to move the patient to another bed. The mattress may be turned or changed easily and with no discomfort to the patient. One method is to remove the pillows and all the top clothes except the sheet and blanket which are folded back neatly over the patient. The under linen is rolled toward the patient, making a firm roll on either side. Two people, one on either side, by this roll lift the patient free of the mattress, while a third assistant draws the mattress out from the foot, turns, and replaces it. A second method is to arrange the clothes as before, to lift the patient to one side of the mattress, to draw it from the side partly off the springs, to place pillows on the springs, to lift the patient on to the pillows, and then to turn the mattress (from the head toward the foot), after which the patient is lifted on to the mattress; the pillows are removed, and the mattress placed in position. The bed is then remade. If the mattress is to be changed, the patient is lifted to one side of the old mattress as before and the mattress is partly drawn from the springs. The new mattress is placed on the springs exposed, the patient is lifted on to it, the old mattress is entirely removed and the new one put in position. The patient is moved to the center of the bed which is then remade. To Move the Patient from One Bed to Another.—Place the beds (if of equal height) close together, loosen the draw sheet and draw the patient to the fresh bed by pulling him on the draw sheet. When the beds cannot be placed together the upper sheet and blanket may be rolled snugly around the patient, who may then be lifted and carried to the fresh bed prepared for him. Both nurses stand on the same side, one supporting the head, shoulders and back, the other the back, thighs and feet. First draw the patient to the edge of the bed, and together lift gently, the patient holding himself stiff. To turn or change a mattress or to move a patient from one bed to another, in many cases it is less alarming and fatiguing for the patient and more convenient for the nurses to lift the patient and make him comfortable on a stretcher during the procedure. Position of the Extremities.—Frequently—in rheumatism, phlebitis, ulcerations, painful joints, sprains or fracture__ one or both limbs may be elevated in order to improve the cir- culation and relieve congestion of blood and pain in the part. In moving or elevating an extremity, move it very gently and sup- port its entire length evenly leaving no hollows. In all cases but particularly in rheumatism in which the slightest movement, jar of the bed, or movement of the floor, or weight of the bedclothes may be extremely painful, move with the greatest care. It is MAKING A HELPLESS PATIENT COMFORTABLE 63 often necessary to immobilize the part by the use of casts, splints, or sandbags, and to protect from the weight of the bed- clothes by the use of a cradle. Phlebitis (inflammation of a vein) usually attacks the femoral or the great saphenous veins in the leg as in typhoid fever or in other infectious diseases, and in surgical cases. It is usually associated with a thrombus or blood clot as the blood tends to clot when the lining of a blood vessel loses its smoothness. This blood clot (as previously explained) if dislodged and set in motion (then called an embolus) may find its way and become lodged in a small artery in one of the vital organs,—the lungs, heart or brain—thus forming an obstruction or cutting off the blood supply. The result is very sudden death. The chief care on the part of the nurse, therefore, is to keep the part very quiet so as not to disturb any clots. The part must never be rubbed, even though the patient feels it might give relief. The part is elevated and an ice-bag is usually applied to relieve the conges- tion. Sandbags are frequently used to limit motion. II. Relieving Discomfort by Preventing Weight and Pres- sure on Sensitive Parts.—Do not allow a weak patient to be obliged to support his own weight—his head, arms or body when sitting up or when turned on one side. When the skin is tender and the patient thin and emaciated support the weight of the body and protect all bony prominences by the use of air-rings or cot- ton rings, and by padding and bandaging joints. Be careful not to put too much air in the rings, that is, not enough to make them hard and unyielding—this causes pressure and may do more damage than the bed: There should be just enough to relieve pressure. When the patient is in danger of developing bedsores, an air or water mattress may be necessary to relieve all pres- sure. Water mattresses are seldom used because difficult to manage. When used the temperature of the water should be 100° F. An air mattress is cool. It supports the weight and relieves pressure as it yields to the body. When used it is usually placed upon another mattress and the air forced into it. Care must be taken not to fill with too much air as this in itself causes pressure sufficient to cause bedsores. It also gives a sen- sation of rolling and bouncing with every move so that there is danger of the patient rolling out of bed. Always watch him very closely. If he is very restless or unconscious put sides on the bed to avoid all danger. Scrupulous care must be taken of both a water and an air mattress, as they are both very expensive. Be particularly care- ful in the use of pins to avoid injury as the slightest pin prick will render them useless. After use they should be disinfected and put away with a small amount of air left in. III. By Relieving Discomfort from Friction, Rubbing or Chafing.—The constant irritation from friction of the elbows, knees, ankles, or back of the head, on the bed or bedding, and the chafing of two surfaces of skin constantly rubbing together, 64 THE PRINCIPLES AND PRACTICE OF NURSIN( J may soon cause the skin to break down, forming bedsores. These parts should be protected by cotton rings held in place by band- aging, or pads bandaged in place, or by the use of cradles, to keep the clothes from rubbing on the part. The feet particularly should be protected, for when the patient is long in bed the cir- culation is poor (shown by the frequent tendency to cold feet) and therefore, the tissues more easily break down, and heal very slowly. Where there is chafing from the surfaces of skin rubbing together the parts should be kept perfectly dry. The circulation should be improved by massage; irritation should be relieved by soothing ointments, and the parts should be separated by the use of pads or dressings. IV. By Relieving Discomfort from Extremes of Tempera- ture, either of the atmosphere, or from the bedding (too much or too little), or from an increased body temperature. See that the patient has sufficient, but not too much bedclothing. Turn and shake the pillows frequently. Pull the drawsheet through to give a cool place to lie on. Fan the upper clothing and raise the clothing by the use of cradles. Apply cold compresses to the head; sponge with alcohol; give cooling drinks. Where the patient is hot and feverish remove the soft pillow and allow him to lie on the cool hard pillow. V. By Relieving Discomfort from Lack of Cleanliness, or from crumbs, wrinkles or moisture in the bed. VI. By Relieving Discomfort from Interference with Bodily Functions—diarrhea, constipation, retention of urine, involun- tary movements from lack of control of the rectum or bladder. CARE OF THE BACK: PREVENTION AND TREATMENT OF BEDSORES The prevention of bedsores is entirely the responsibility of the nurse, so that at the very beginning of her training, long before being entrusted with a patient, a nurse should learn how to care for a patient so as to avoid them. Bedsores are rarely unpreventable and are usually due to carelessness. The neglect and ignorance of one nurse may, in a few hours, undo the most skilled and devoted care of another. An "ounce of preven- tion is worth a pound of cure." Even a mild bedsore once de- veloped is hard to cure and requires much more diligence, time, thought, and worry than prevention. Since the advent of the trained nurse, bedsores are almost obsolete. A nurse in training may have little experience in the care of bedsores, so thoroughly are the rules of prevention observed. Patients who have been ill at home for some time however, frequently come to the hospital with bedsores, resulting from lack of knowledge or skill, even when they may have received the most devoted attention of relatives or friends. Nature and Causes of Bedsores.—Bedsores or pressure sores result from an interference in the circulation in a part due to MAKING A HELPLESS PATIENT COMFORTABLE 65 pressure: The pressure may result from the weight of the body lying too long in one position, or. from splints, casts, bandages, or bedclothes. It is frequently aggravated by heat, moisture, lack of cleanliness, decomposing and irritating substances on the skin such as perspiration, urine, feces or a vaginal discharge. Wrinkles in the undersheet, crumbs, friction from restlessness, rubbing of the bedclothes or of two surfaces of the skin in con- tact, together with heat and moisture, as in a pendulous abdo- men, all predispose to bedsores. Anything which interferes with the circulation or nutrition of a part, especially if the nerve supply is deficient (as in a broken back, and in some fracture cases, and after operations when nerves have been removed) is likely to result in a pressure sore. Those most in danger of developing bedsores and who, there- fore, require special care are: 1. Patients with poor circulation from old age, lack of exer- cise in a prolonged illness, certain forms of heart disease, neph- ritis with poor circulation and edema. 2. Patients with anemia in which the quality of the blood and the nutrition of the tissues are poor. 3. Patients with a malignant growth such as cancer—cancer destroys as it goes, and the poisons absorbed from the dead tissue cause anemia. 4. Patients suffering from a prolonged infectious disease, such as typhoid, pneumonia, or tuberculosis. These patients are poorly nourished, their vitality is low and the high fever and the bac- terial toxins absorbed cause an increased destruction of the tissues. 5. Patients suffering from paralysis—the part rests like a dead weight, the nerve supply is deficient and the lack of exercise makes the circulation, and therefore the nutrition, poor. 6. Very thin, emaciated patients with prominent bones. 7. Patients with no control of the bladder or rectum with an involuntary passage of urine or feces. 8. Those with a thin, tender, dry skin easily chafed. 9. Those with excessive obesity due to the weight of pendu- lous parts and to faulty metabolism and nutrition of the tissues. 10. In patients suffering from diseases of metabolism, such as diabetes. The Danger Points on the body are the bony prominences (where there is no rich supply of blood to nourish, and over which there is only a thin layer of skin)—the coccyx, hips, elbows, heels, shoulder blades, knees, elbows, the inner malleoli (inner surfaces of the ankles), and the back of the head in infants. Between folds of flesh—under the breasts, or the abdo- men, etc.—may become sore due to the heat, moisture, and chafing. Why bedsores are Dangerous and Must be Prevented.— They are a source of great discomfort to the patient. They cause destruction of the tissue and are a great drain on the 66 THE PRINCIPLES AND PRACTICE OF NURSING patient's strength in the effort to battle against the injury and to repair it. They are very easily infected and the patient may die from the absorption of poisonous substances, or the kidneys and other organs of elimination may break down from overwork in the effort to eliminate the toxins. The Symptoms of a Bedsore.—Nature's danger signals.—The first symptoms are heat, redness, tenderness, discomfort, and smarting. (When the skin is broken a bedsore has formed.) The heat and redness show that Nature has come to the rescue by circulating an increased amount of fresh arterial blood laden with food and oxygen to nourish and revive the injured tissue, and white blood cells to act as soldiers in preventing further injury, and as scavengers in carrying away the dead or damaged cells. The tissue is damaged and congested, but is still healthy and the chances of recovery are good if immediate and constant care and attention are given and the patient's condition is favor- able—if neglected, a bedsore will surely result. If the pressure is not relieved the circulation is greatly inter- fered with, the tissues become more congested, and the circula- tion in the part is finally shut off. The superficial veins first feel the pressure so that the outflow of blood is shut off and the vessels become engorged with venous blood which mechanically prevents an inflow of arterial blood. The continued pressure finally cuts off the supply of arterial blood. This congestion of the tissues with venous blood makes the part blue, purple or mottled, like a bruise, also cold and without sensation. If the pressure is not immediately relieved and the circulation restored, the tissues will surely die and a true pressure sore will result. Dead tissue cannot be restored to life, but remains as a slough (dead flesh in living flesh) which must either be absorbed and carried away by the blood or removed externally before healing can take place. Ferments or enzymes liberated from the dead and dying cells gradually decompose or soften it so that it may more easily slough away (to slough means to separate the dead from living tissue), or be absorbed by the blood and later elimi- nated by the kidneys. When the slough is removed an open raw surface or ulcer remains. This decomposition and sloughing can be aided by the application of hot compresses but one should never attempt to pull the slough away on account of the danger of hemorrhage from the relaxed congested blood vessels. During the normal sloughing process the blood vessels in the dead tissue gradually shrink and the ends in the healthy surrounding tissue close or anastomose with other vessels so that hemorrhage is prevented and the circulation is readjusted. Preventive Measures.—Remove all the possible sources of dan- ger. Remove all pressure by the use of air-rings for the end of the spine (avoid inflating with too much air and making too hard), cotton rings (for the heels, elbows, or back of the head), pillows, pads, or an air mattress. Remove pressure on an extremity by suspending and supporting it: Turn the patient fre- MAKING A HELPLESS PATIENT COMFORTABLE 67 quently—the position may have to be changed every hour. Avoid the careless use of the bedpan such as using a chipped pan or by leaving the patient on it too long; cover the pan with a pad when there is danger of a bedsore. Keep the patient abso- lutely clean and dry; change a damp gown or bed linen immedi- ately: When the patient has involuntary passages of feces or urine protect the bed with a large oakum pad which absorbs readily, and is easily changed, and saves the laundry. When a patient has a vaginal discharge watch the back carefully as the discharge is apt to run up the back under the dressing or pad and excoriate the skin. Absolute cleanliness is necessary. Wash with boric acid to remove decomposing urine and other discharges and oil the surface to prevent the urine, etc., from coming in con- tact with and irritating the skin. Rub the part and the surround- ing tissue frequently with alcohol—at least morning and eve- ning, or three times a day, or every four, every two, or every hour as the case demands. The alcohol cools, refreshes, hardens, drys the skin, and prevents chafing, and the rubbing stimulates and restores the circulation. When the skin is broken, rub around the part only. Rub with a circular motion away from the part so as to stimulate the outflow of the stagnant venous blood which will mechanically be replaced by the inflow of arterial blood. The circulation may also be stimulated by the application of hot water. Keep the skin dry by the use of powder after rubbing with alcohol. See that the patient's gown, the bed linen, and the coverings on air-rings or cotton rings are clean, dry, cool, and free from wrinkles or crumbs. Pad the elbows and knees or other parts exposed to friction. Where there is a tendency for the skin to chafe, rub with olive oil or cocoa butter. Keep surfaces of skin or folds of flesh apart and apply an antiseptic powder to keep the parts dry. The Treatment of Bedsores.—Report the first symptoms of a bedsore to the headnurse so that proper steps may be taken to prevent further damage. The treatment of a bedsore must be prescribed and the dressing performed by the doctor. It must be kept surgically clean like any other wound (by the use of anti- septics and the application of sterile dressings), and every aseptic precaution taken to guard against infection. If infection occurs there will be a discharge on the dressing. The ulcer will grow wider and deeper with a greyish unhealthy-looking surface and the surrounding tissue will look red and angry with signs of breaking down. The treatment prescribed depends upon the condition of the wound and the rate at which healing or repair takes place. If there is no discharge and the surrounding tissue and the surface of the ulcer look healthy, the only treatment may be to keep it dry and surgically clean by the application of an antiseptic powder and a sterile dressing. A paste made of castor oil and bismuth, which is protective and drying, may be used. Stearate of zinc or boric acid powder are antiseptic, healing, and stimu- 68 THE PRINCIPLES AND PRACTICE OF NURSING lating. When the healing is very slow and the sore is a long time in closing, repair may be stimulated by the application of balsam of Peru or Scarlet Red ointment. Ichthyol ointment increases the resistance of the tissues, promotes the absorption of inflammatory products, and stimulates the healing process. It is also soothing to painful areas. Zinc oxide ointment makes a soothing protective dressing. It is insoluble in water and there- fore protects the skin from moisture such as urine or excessive perspiration. Exposure of the wound to electric light rays both dries and stimulates, and is very effective in healing. When infection has occurred the ulcer may be cleansed by the use of antiseptics such as peroxide of hydrogen or Dakin's solution, and provision made for free drainage by packing with sterile gauze. CHAPTER VIII REST AND SLEEP In the nursing care of sick people one of the most influential factors and one of the first and most responsible duties of a nurse is to see that her patients have sufficient physical and mental rest and sleep. Sleep is often of much greater importance than all the other measures devoted to the treatment of the disease itself. The Importance of Sleep.—Sleep, with rest of mind and body, is absolutely essential to the patient's recovery. One hour of natural sleep, Nature's restorative, restores the patient more than all the methods devised by man. Our whole, mental and physical welfare depends upon it. The brain controls all our conscious life and regulates the functions of the whole body. It is our delicate, highly developed and highly specialized nervous tissue of the brain which makes us differ from animals, enabling us, not only to adapt ourselves to our environment, but to adapt our environment to ourselves. The cells of this very delicate nervous tissue are subject to the same laws as other cells. They become fatigued by overactivity or excitement, by depression and lack of use, and by the accumulation of waste products which act as poisonous drugs paralyzing all the activities of the brain, and, therefore, the function of many organs. The worn- out cells must have rest and sleep to rebuild and repair the damage. There is nothing more trying and exhausting than sleepless- ness. The whole appearance and condition are changed after a quiet, restful sleep which must be secured at all costs. "One of the most dreadful punishments that the Chinese have is to kill a man by want of sleep, and he generally dies in less than a fort- night from the time that the punishment begins." x Every sensa- tion of pain, discomfort, fear, worry or distress of every kind is magnified a hundredfold during a sleepless night. It is the time when doubts and fears assail us. Even in health one hour seems like a whole night. The sick dread the night and say that they always feel worse at night. The Causes of Sleep:— 1. Anemia of the brain.—The brain must have blood to carry on its work; therefore, by lessening the volume of blood flowing in the vessels of the brain, we lessen all its activities. 2. The withdrawal of all stimuli or messages, through the eyes, the ears, the sense of touch or smell, the thoughts, and other 1 Lectures on the Action of Medicines by Dr. Brunton. 69 70 THE PRINCIPLES AND PRACTICE OF NURSING pathways. Messages either directly stimulate the cells of the brain or stimulate the circulation. 3. The accumulation of waste products in the body as, for instance, following exercise in the open air, due to the increased metabolism or combustion. How to Secure Anemia or a Lessened Volume of Blood in the Brain.—There is only a certain volume of blood in the body—if the volume is increased in one part it must be lessened in another. The circulation is greatly affected by position, the condition of the heart and blood vessels, the quality of the blood, the digestion, the temperature of the body and surroundings, the occupation, mental and physical, and the emotions. Numerous experiments show that there is a lessened amount of blood in the brain during sleep. The lessened activity is shown by the slower pulse rate and respiration. 1. Have the patient lie down. The heart beats more slowly and is therefore sending less blood to the brain. When sick peo- ple are obliged to sit up constantly (usually because of heart disease with poor circulation) their sleep is very fitful so that they must have very tender care. Avoid all causes of restless- ness, for, when the body is still the circulation is slower and less blood is circulating in the brain. 2. Most people, however, must have one or two pillows. in order, by position or gravity, to lessen the volume of blood in the brain. Sometimes one will fall asleep when sitting up in a chair (the brain is anemic), but be unable to sleep when at last one can lie down—the change in position has, by gravity, in- creased the blood supply in the brain. For the same reason anemic patients will be drowsy during the day when sitting or walking, but be unable to sleep while lying down. In anemia the heart is weak and the circulation poor, so that during the day when standing, sitting, or walking there is an increased volume of blood, by gravity, in the extremities and in the muscles where it is necessary for their work in walking, etc. When the anemic patient is lying down, the feet being elevated and the muscles at rest, the blood returns to the heart and is pumped to the brain, which as a result then becomes active, because the relaxed anemic blood vessels have lost their tone and cannot con- tract to prevent congestion. Sick people are very frequently or usually become anemic so that special care is required to pre- vent sleeplessness. 3. Active brain workers, sometimes, can only sleep with the head elevated with several pillows because the congested blood vessels keep the brain active. Try to keep patients from reflec- tion, reading or work requiring thought just before bedtime. Pro- tect patients from conversations with visitors, and anything likely to excite painful emotions, such as excitement, anger, irritability, (note the flushed face, indicating congestion, with excitement, or anger), fear, worry or nervousness. For instance, do not keep a patient waiting for the bedpan, for medications and other similar REST AND SLEEP 71 necessities, until the patient is too uncomfortable, "too upset," or "past" sleeping. All of these conditions increase the volume of blood in the brain. Cold compresses applied to the head, or rubbing the forehead with a volatile liquid, like aromatic spirit of ammonia or alcohol, are cooling, and will frequently relieve the congestion and sleeplessness. 4. Massage of the limbs, back, or back of the neck, a hot bath or foot-bath, the blanket pulled well up over the shoulders, a hot-water bottle to the feet or abdomen all increase the volume of blood in the body and extremities, and therefore lessen the supply in the brain. Sometimes patients cannot sleep because too cold, especially if their feet, shoulders or abdomen are cold: Note how one draws the knees up in the effort to protect and warm the abdomen, for there is a direct relation between the blood vessels and blood supply of the feet, abdomen, and brain. When the feet or abdomen (the stomach and intestines) are cold, there is less blood there and more in the brain, so that the appli- cation of warmth—an extra blanket or a hot-water bottle—acts as a powerful hypnotic. Old people in particular require special care at night. Their circulation is poor and they are apt to feel the cold very quickly. Always see that they have extra warmth. Again there is a saying that a man is as old as his arteries, which means that as one grows older the arteries lose their tone or elas- ticity, the power to contract or relax promptly as they should to the pressure of blood, so that they do not contract readily when one is lying down or regulate the supply of blood in the brain. Massage lessens the rigidity of the blood vessels, and makes the circulation more normal so that it is very beneficial for old people. 5. Sometimes patients cannot sleep without something to eat. One of the first duties of the night nurse is to give her patients a hot drink. This draws the blood away from the brain to the abdomen. This is illustrated in the following amusing and instructive tale told by Dr. Brunton. "Perhaps one of the best expositions of sleeping and waking ever given was that of Mayow, who lived about 200 years ago, and in his time people said that all the functions of the body were carried on by what they termed vital spirits. These were supposed to be little imps that were present all over the body, and each one had its work to do; and 'if,' said Mavow, 'a man takes a big dinner, all the vital spirits have to go down into the stomach in order to carry on digestion, and the man naturally goes to sleep, and cannot easily think; but if the man will try to think after his dinner, and succeeds in doing so, the vital spirits will go up to his brain to do the thinking, leaving the stomach to its own devices, and consequently the food is not digested.' If we substitute the word 'blood' for 'vital spirits' we have here a very good exposition of the modern physiological theories of digestion and of sleep." When applying heat to the external abdomen or to the interior of the stomach, see that the hot-water bag or the drink is not too 72 THE PRINCIPLES AND PRACTICE OF NURSING hot. The stomach being near the heart and being very richly supplied with blood vessels, the heat may stimulate the heart and the circulation and in this way increase instead of lessen the blood supply of the brain. To Induce Sleep by the Withdrawal of all Stimuli or Mes- sages to the Brain or Spinal Cord, that is, to shut it off from all disturbing factors in the body itself or its surroundings.— These stimuli are conveyed through the eyes, ears, sense of smell or touch, the sensations of heat, cold, pain, discomfort, an uncom- fortable position, or close, stuffy air. Messages are constantly being sent to the brain or cord (even when we are sleeping) for the sentinels or nerve endings are always on guard and, some- times even though we are asleep, the brain or cord will respond. For instance, when asleep in an uncomfortable position a healthy person will often change this position without waking; or when too hot or too cold will throw the clothes off or pull them around him without waking. Notice a person asleep when sitting up in a chair, how the head nods, the body sways, but with convulsive jerks swings back into position, maintaining its equilibrium with- out waking. Such a sleep (disturbed by dreams or discomfort, etc.), is not the sound, healthy, restful sleep one desires for the sick. A sick person will not be able to make these adjustments and will probably be aroused from his sleep and be unable to sleep again. A nurse must see that nothing disturbs the patient's sleep, especially during the first sleep, for the shock of being aroused makes the brain wide awake and intensifies a hundred- fold all the pain and worry, that would have been dulled and driven away by a more prolonged sleep. "The more the sick sleep the better will they be able to sleep." To withdraw all stimuli, have the room darkened, quiet and well ventilated. See that the patient is free from excitement or worry and not "past her sleep" from nervousness or any other cause. Allow no painful dressings or treatments, no startling news or noises, such as rattling of dishes, windows, or utensils, banging doors, or cracking ice. The nurse herself must be quiet in her movements and speech. See that the number of visitors is limited, that the ward is quiet during the visiting hour, that visitors do not in any way annoy or disturb very sick patients, and that they do not stay too long. See that the patient is com- fortable and warm, free from hunger and thirst, and that all her needs (such as the use of the bedpan) and requests are attended to. Sleep may be produced by the accumulation of waste prod- ucts in the body, which act as a drug or poison. It has been suggested that this explains why a bird sleeps with its head under its wing, why a dog sleeps with its nose buried under its paw and why some people sleep with their heads covered by the bed- clothes. In each case the elimination of carbon dioxid and the absorption of oxygen is interfered with. One usually goes to sleep as soon as the head touches the pillow after exercise in the REST AND SLEEP 73 open air, due to the absorption of a large amount of oxygen, increased combustion and increased formation and accumulation of carbonic acid gas. During the day the waste products of metabolism accumulate and in time act as a hypnotic. During sleep these are gradually eliminated. Sick people are denied this healthy form of exercise so that sleep does not come so readily. Drugs—hypnotics, narcotics or soporifics—are to be used only when absolutely necessary. The order left for a hypnotic fre- quently reads, "to be given if necessary." Here is an oppor- tunity to show what intelligence and skilled nursing can do. Every art should be tried before resorting to the use of the drug which, in most cases, is adding another poison which may inter- fere with the digestion, the action of the heart or other organs in the already crippled body. THE PREPARATION OF THE PATIENT FOR THE NIGHT The.purpose of the preparation is (1) to find out the patient's mental and physical condition; (2) to refresh after the various discomforts of the day; (3) to remove the causes of restlessness and sleeplessness—worry, excitement, wrinkles, crumbs, aching limbs and back, noise and light, etc.—so that the patient may have a sound, healthy, refreshing and unbroken sleep. The Condition of the Patient at the End of the Day.—Ward patients are awakened at an early hour; the day is long and may be monotonous and dreary, or the patient may have passed through various trying ordeals and be exhausted by pain, dis- comfort, by the long day in bed with hot, aching, cramped limbs, by visitors, by worry or excitement and by the active, sometimes trying scenes around him. The Condition of the Bed and Surroundings.—The bed will often be disordered; the sheets loose, crumpled, wrinkled, hot, damp and covered with crumbs; the pillows will be hot and disordered. The Evening Toilet.—Screen the patient, and bring the nec- essary articles—a basin of water, alcohol, powder, comb and brush, mouth wash and articles necessary for cleansing the mouth, clean linen if necessary, and whatever may be neces- sary for the special needs of the patient. The patient should be allowed to use the bedpan. If the upper bedclothes are loosened and turned back at the foot (without exposing the feet) the clothing will be aired and cooled, and the feet will be given more freedom. This is very refreshing, after having been tucked in tightly all day. Cleanse the mouth, face, hands and back. Allowing the patient to dabble his hands in the water is refreshing, soothing and rest- ful. Rub the back with alcohol and powder, giving particular attention to parts which are red (rub until the redness dis- 74 THE PRINCIPLES AND PRACTICE OF NURSING appears), or in danger of becoming sore. If the patient is wearing a binder loosen it when washing or rubbing the back. Inspect dressings for bleeding or discharge and see that they are reinforced if necessary. If the patient's gown or binder are soiled or damp, replace them with clean ones. Remove all crumbs from the patient's gown or bedlinen. Loosen the drawsheet, pull it through to give the patient a cool place to lie on. Tighten the under linen so that it will be absolutely smooth and free from wrinkles. Remove, shake, turn, and rearrange the pillows. Brush and comb the hair, if necessary, and other duties allow it. Straighten the upper bedding. If the patient has a hot- water bottle, ice-cap or water pitcher see that they are re- plenished. Give any special attention the patient may require and attend to all requests. Report and chart the condition of the patient. Especially note any change for the worse, any signs of restlessness or delirium which are apt to develop and become worse, and perhaps violent and dangerous, during the night. Special precautions must then be taken (such as putting "sides" on the bed, padding them with pillows to prevent him from hurting himself, and moving him to a place where he can be closely watched by the night nurse). The night nurse should be warned of the patient's condition and possible developments. The nurse in charge of the patient dur- ing the day should also see that all supplies, dressings, milk, broth, medications, clean linen, etc., which may be required for the patient at night, are on hand. The environment of the patient should also be in order—the table cleared of all fruit, soiled dishes and flowers, etc., and the service rooms left in order. THE IMPORTANCE OF SLEEP FOR INFANTS AND CHILDREN Sleep has an added importance for infants and children. An adult can do with less sleep and less food because he has com- pleted the serious business of growing. He can afford to use all the calories supplied by the food he eats to produce heat and the power or energy to do work, that is, to lead an active life, merely reserving enough calories or energy to repair the tissues worn out in the process. In infancy and childhood, however, besides the calories necessary to produce heat, to produce energy to carry on the processes of life—breathing, circulation, digestion, etc., and to repair tissues, a large amount of energy must be conserved to provide for growth. Growth, developing, gaining strength and the power to protect itself is the body's chief con- cern during infancy and childhood. During the first year an in- fant normally trebles his weight. For this reason during the first year an infant requires 45 calorics in food for each pound of body weight, whereas a man weighing 150 pounds, while at rest in bed requires only 33 calories. For the same reason infants and REST AND SLEEP 75 children must have more sleep because (1) during sleep fewer calories are used to produce heat; the temperature falls during sleep; (2) fewer calories are needed to produce energy for work or to repair tissues—the body is at rest; there is less wear and tear on the tissues; the pulse and breathing are slower so that during sleep most of the energy can be devoted to growth. Very sick, weak babies usually sleep a great deal, are very quiet, mo- tionless and do not even cry because crying is exercise and uses up energy. This is Nature's way of conserving energy necessary for growth and to increase resistance against the disease. Sleep is, therefore, essential if the infant is to grow. The Amount of Sleep Required.—A new-born babe (from birth to the end of the first month) sleeps almost continuously. He does nothing but sleep and eat, sleeping from 20 to 22 hours, usually waking a few minutes for feeding. During the first six months he should sleep from 16 to 18 hours; at the end of the first year, about 15 hours; at the end of the second year, 13 to 14 hours; at the end of the fourth year, 11 to 12 hours, from the ages six to twelve, 10 to 11 hours; from ten to fifteen years, about 9 hours. Character of the Sleep.—The sleep of the new-born is usually deep. The slumber of a normal infant is sound, natural, un- broken, undisturbed—the soundness of the sleep is an indication of well-being. Wakefulness or a restless, broken slumber is al- ways an expression of illness. Conditions Necessary for Proper Sleep.—Nature provides for this sound slumber by delaying the development of the nerv- ous system. The brain is not developed, and the sensations of sight and hearing, etc., are not acute. It is, therefore, not neces- sary to whisper, to keep quiet, or to stop any of the usual activi- ties about the room or ward. The position of the infant should be changed often during sleep for the same reasons that an adult changes his own position frequently. The soft bones of the head in young infants become flattened and deformed if they are forced to lie constantly in one position. Changing the position will not disturb the sound slum- ber of an infant, or if it does, he soon falls asleep again. No pacifiers, finger sucking, rocking, or "walking the floor" are necessary and should not be permitted. While an infant is not very sensitive to its surroundings, sud- den noises, a bright light and all causes of physical discomfort should be avoided. He should have the proper amount of covers, should be dry and warm, but not too warm. Too much heat with perspiration is very weakening. Moisture from perspiration or urine, etc., predisposes to chilling, colds and pneumonia. Fresh air is essential. Proper habits should be formed from the beginning. An in- fant should be placed in a dark room, while awake and left unattended. He should sleep the regular amount and be put to bed at a definite time each day and night. As the infant grows 76 THE PRINCIPLES AND PRACTICE OF NURSING older his brain develops and he becomes more sensitive to his surroundings. All causes of mental excitement, of nervousness or fear of the dark, should be avoided. A child should not be told stories which excite or stimulate the imagination. Visits from parents at the evening hour sometimes pacify but often excite the child and make him homesick. A child should not be punished by being put to bed. Although sleep is essential for infants, they should always be awakened regularly for feedings and they should not be allowed to fall asleep during feedings. CHAPTER IX THE MORNING TOILET The Beginning of a New Day for Patients and Nurses.— The nurses arrive freshened by a good night's rest, ready for the day's work. The patients also begin a new day with varying feelings toward what the day has in store for them. Some will have had a good night's rest while others are exhausted by a long night of wakefulness and pain: Some are very low, not ex- pected to see the light of another day: Some look forward with hope to another day nearer to recovery, to interest in the varied scenes and activities around them, while others are bored by the monotony—each day for them is much like the previous day: Others look forward with dread of what the day has in store for them—an operation, painful treatment or examination, or a long day of suffering, while some may be too sick to be conscious or care: Some are going home restored to health, while others have no hope of ever going home or being well again. To a new pa- tient everything will be new and strange, and he will be inter- ested in everything as it may relate to him. His first impres- sions on the beginning of this first day are very important and are indelibly impressed on his mind. A nurse should be quick to understand and feel the needs of each of her patients. This understanding depends upon sympathy—the power to feel with others and to feel as others feel. She should minister first to the patient who needs her attention most. The ward in the morning should be bright, well ventilated, quiet and in order. The nurses should be cheerful, bright, brisk, fresh and clean, and should begin their work with a will. Each should have her assigned duties so that the work will proceed quickly, smoothly, systematically, and without confusion. The day begins with making beds—with the patient in bed, or with empty beds when the patients are allowed up; taking and charting the patients' temperature, pulse, and respiration; the morning toilet, breakfast, treatments, cleaning, dusting, and putting the ward in order. All should be done, if possible, be- fore the doctors' rounds at 9 or 10 A. M. MAKING A BED WITH A PATIENT IN IT In making a bed with a patient in it, observe the following principles: Screen the patient and allow no unnecessary expo- sure or drafts. Have everything at hand before beginning. 77 78 THE PRINCIPLES AND PRACTICE OF NURSING Study the patient's condition and have everything necessary for his care and comfort that his condition may demand. Remove all the upper clothing except one blanket—a patient should never be left without a blanket except in hot weather. Fold the spread and place all the clothing on one or two chairs to air; do not allow them to touch the floor. Remove the pillows also unless this is uncomfortable for the patient. One pillow may be left. The removal of the pillows provides a change of position, which is usually restful to the patient: It allows the pillows to cool, and makes it easier for the patient to turn and for the nurse to work. Loosen the lower bedlinen. Shake out all crumbs from the patient's gown, or change it if damp or soiled. Remove the rubber and draw-sheet and allow them to air. The rubber is hot and becomes uncomfortable, while both are apt to become wrinkled and disordered. Brush all crumbs from the lower sheet or change if necessary. Move the patient from one side of the bed to the other as the occasion demands, but never disturb a sick patient more than necessary, and in every possible way con- serve his energy. Straighten the mattress and tighten the under sheet. Replace the rubber and drawsheet and see that they are tight and smooth and in the proper position. Shake, turn, and replace the pillows and the upper bedclothes. Before removing the screen make sure that your patient is comfortable. Remove all the articles used in the toilet and see that the bed, table, and chair, etc., are in perfect order, and that your work has a fin- ished appearance. THE BED-BATH The morning toilet consists of the bath, care of the mouth, and teeth, and care of the hair. The bath may be a full bed-bath or a partial bath. The Value and Purpose of the Bath in Disease.—Sick people are often weak, tired, exhausted, uncomfortable, hot and fever- ish. In patients who are suffering from a prolonged illness, the circulation in the skin, and its nutrition may be so poor that it cannot perform its proper functions, and may break down, with the formation of bedsores. Again, in the different diseases from which they may be suffering, the functions of various organs may be impaired and this may interfere with, or increase the work of the skin. For instance, in diseases of the heart, the cir- culation in the skin may be so poor that there is not enough heat to vaporize the perspiration so that the patient is covered with a cold, clammy sweat which is most uncomfortable. It also predisposes to chilling, colds and pneumonia. In other diseases, the work of the skin may be greatly in- creased. For instance, when the kidneys are diseased and fail to eliminate waste products as they should, extra work is thrown upon the skin. Sometimes a layer of urea (the chief waste product in urine) is formed on the skin and is spoken of as THE MORNING TOILET 79 "urea frost." Other abnormalities, often very irritating to the skin if allowed to remain, are excreted in the perspiration during the course of various diseases. For instance, in fevers, increased lactic acid is eliminated and in rheumatism, increased uric acid, giving the perspiration (which is often profuse) a very sour odor. Acids are always irritating to the skin. Again, in the excessive perspiration from the feet, it frequently contains leusin, tyrosin, or ammonia which, when decomposed, have a very disagreeable odor and are very irritating. The purpose of the bath is, therefore: 1. To refresh the patient and relieve discomfort from posi- tion, heat, moisture and other causes. The beneficial effect of the water is aided by the use of massage, which stimulates the circulation, and by the use of alcohol which cools, dries, hardens, and refreshes the skin. 2. To cleanse from—(1) external dirt (dust and infectious material) ; (2) internal dirt (excretions from the body, the wastes of metabolism); (3) decomposing substances which are irritat- ing and give rise to disagreeable odors. Number of Baths Desirable.—Very sick patients should have a full bath daily. A daily bath is always desirable, but in the public wards of a hospital the amount of work and time involved make this impossible. Usually two complete baths are given weekly, a partial bath being given on other days. The best time for bathing is before breakfast or before retir- ing. One hour after a meal should elapse before bathing, in order not to interfere with the processes of digestion. There is only a certain volume of blood circulating in the blood vessels of the body. During digestion an increased amount of blood is required in the vessels of the stomach and intestines. Bathing and rubbing the skin causes an increased amount of blood to flow through the vessels in the skin and thus robs the vessels in the stomach, intestines, and other organs. The Beneficial Effect of the Morning Bath.—Any doubts that one may have as to the beneficial effect of the morning bath are dispelled by observing its effect on a sick patient. The pa- tient's chart, her exhausted appearance and condition, her pulse weak and irregular, may indicate a very restless, sleepless night and a condition very low, approaching death. After a warm bath, massage, change of linen, and remaking of the bed, if skil- fully done, the patient will usually doze off into a peaceful, sound, restful slumber, from which she will waken refreshed with all her vital powers refreshed and restored: Her pulse, breathing, and whole appearance and condition will show improvement. When the doctor arrives, he does not see the patient at her worst, does not see all the symptoms which really indicate her condition. This emphasizes the importance of close, accurate observation and recording, and the necessity for the doctor seeing the patient sometimes before the morning toilet. Sleep is a great blessing, merciful to all. 80 THE PRINCIPLES AND PRACTICE OF NURSING Preparation for the Bath.—Before beginning the bath see that the room is warm (70 to 75°), that the windows are closed, that the patient is protected from drafts, and that everything necessary for the bath is at hand. Method of Procedure.—The technique will vary in different hospitals, but the underlying principles will be the same in all. The articles used will vary somewhat according to the technique, but will include a large basin of water at 100 to 105°, a warm bath towel and face towel, wash cloths, soap, alcohol and nail brush, comb and brush, talcum powder, articles for cleansing the mouth, protection for the bed and protection for the patient for cover and warmth. During the procedure only the necessary exposure should be permitted (no exposure is really necessary) both to guard the patient's feelings and to prevent chilling. The patient is covered with a bath blanket and all the upper bedclothes are removed or turned to the foot of the bed. One pillow only is left under the head unless this position is uncomfortable. Remove the gown. The patient may be allowed to cleanse her mouth and teeth and also to take her own bath, if her condition permits, but the nurse is responsible for seeing that it is thoroughly and properly done. Proceed in the following order: The face, ears, neck, chest, arms and hands, abdomen, back, thighs, legs, feet, and pubic region. Give special attention to the ears, between the fingers and toes, axilla, umbilicus and pubic region. Work quickly and wash with firm but gentle pressure. Dry each part separately and thor- oughly. After drying the back rub with alcohol, to cool, refresh, and harden the skin, and with powder to refresh and dry. Give particular attention to parts that are red, to the end of the spine, and to all prominent parts. In washing the feet, place the tub on the bed (protected with a towel), place the feet in the tub, and if dirty, allow them to soak. Then scrub until thoroughly clean. While the feet are soaking, the finger nails may be cleansed and trimmed. Remove the feet from the tub and dry them thor- oughly, drying well between the toes. Cleanse and trim the nails. The gown may be replaced after drying the back, or after the bath is completed. The care of the hair is left until the gown and bedclothes are replaced and the patient is quite comfortable. The care of the hair is a somewhat lengthy process and the patient may become chilled if not properly covered. The upper bedding and pillow are protected with a towel and the hair brushed, combed and braided before shaking and replacing the pillows. Work quickly, quietly, and smoothly when bathing the pa- tient. Do not dawdle, allowing the water to get cold, and ex- hausting the patient. Make the patient feel that your mind is on the bath and not on other work waiting to be done. In wash- ing the patient, do not allow the ends of the washcloth to dangle. They will feel cold and most uncomfortable; expose and finish THE MORNING TOILET 81 one part at a time. Do not use more water than is necessary, or allow it to drip over the patient. When the bath is completed, re-arrange the bedclothes and re- move the bath blankets or towels, etc. Shake and replace the pillows. If the patient feels chilly place a hot water bag at the feet and give him a hot drink. Clear away the utensils, etc. See that they are clean and dry, and that the blankets are neatly folded and everything put in its proper place. See that the table, chair, and bed are in perfect order before removing the screen. When finished, inspect your work—is your patient com- fortable and does your work measure up to the standards and ideals you have set? When a full bath is not given a partial bath—cleansing the mouth, face, hands and arms, back and pubic regions—is given. In some cases the morning toilet (when a full bath is not given) consists in washing the face and hands, cleansing the mouth, rubbing the back with alcohol and powder, combing, brushing, and braiding the hair, changing the soiled linen and remaking the bed. The most scrupulous care should be given to the mouth and back. Every means of making the patient comfortable should be attended to. When the bed-bath is being given to a patient on admission, it is frequently necessary to use a large amount of soap and water so that extra protection is required for the bed. A large rubber is used. Benzine, ammonia, tincture of green soap, and a brush will be necessary if the feet are very dirty. Otherwise the method of giving the bath is the same. THE CARE OF THE MOUTH AND TEETH Mouth hygiene, the sanitary mouth, or the care of the mouth and teeth is said to have ushered in a new era in preventive medi- cine. It is one of the main points of attack in preventing or curing disease, and in the preservation of health. Importance of the Care of the Mouth.—As we have learned in the study of bacteriology, the mouth is an ideal incubator for germs as it contains food, air, moisture, and warmth. Even in healthy mouths bacteria are probably always present while in neglected mouths they are abundant and multiply rapidly. As a result of experiments, 100 varieties of lactic acid producing bacteria have been found in a neglected mouth and 50 varieties in a decayed tooth. These bacteria break up the carbohydrates, causing fermentation with the formation of acids. The Effect of Acids on the Teeth.—Acids destroy the enamel and the pulp of the teeth and allow the invasion of bacteria which cause abscesses at the roots of the teeth and pyorrhea alveolaris. Devitalized teeth are very prone to infection at the roots. The presence of bridgework and plates, etc., makes the mouth difficult to keep sanitary and gives rise to infection. 82 THE PRINCIPLES AND PRACTICE OF NURSING The Effect of a Neglected Mouth on Digestion.—A neglected mouth spoils the appetite and decayed teeth interfere with mas- tication. The pus from abscesses, and the acids and bacteria swallowed interfere with digestion. The bacteria cause fermen- tation in the stomach and intestines with the formation of gases (tympanites). Infection in the mouth may spread to and in- terfere with the function of the salivary glands. The Effect of a Neglected Mouth on Other Parts of the Body and the General Health.—Infection may spread to the sinuses, to the eyes, up the Eustachian tubes, to the ears, to the tonsils, to the salivary glands, and the cervical glands. From diseased tonsils, rheumatism, endocarditis, and chorea may develop. In- fection and abscesses at the roots of teeth are associated with arthritis, nephritis, gastric ulcer, appendicitis, endocarditis and other serious diseases. From a neglected mouth in typhoid a patient may reinfect himself. A neglected mouth is a menace to the entire system. The kind of patients apt to develop bad mouths, who there- fore require special care, are:—(1) Unconscious or dying pa- tients; (2) patients suffering from fevers, such as typhoid and pneumonia, in which the lips, tongue, and membranes of the mouth become dry and cracked. Food, milk, dried epithelial tissue and bacteria get into the cracks forming thick tenacious deposits called sordes, very difficult to remove. If not kept clean, very painful ulcers on the tongue and cheek, tympanites, and infection of the ears or glands result; (3) in many diseases, in almost all forms of illness, and in all very ill patients, espe- cially those on liquid diet, the tongue becomes furred. General Care of the Mouth.—It should be kept clean and moist, and cleansed with an antiseptic solution frequently. Mouth breathing, and any mechanical, or chemical injury to the gums with tooth brushes, pastes, or medicines must be avoided. The Daily Routine Care.—The mouths of convalescent pa- tients should be cleansed three times a day, or at least in the morning and evening. Very ill patients, patients with a high fever, or those with difficult breathing who breathe through the mouth, should have their lips and mouths cleansed more fre- quently: They should be cleansed before fluids, and the mouth should be well rinsed after fluids. The tongue should not be cleansed directly after fluids, as it may induce gagging. Special care should be taken in rinsing and cleansing the mouth after milk. The patient should be given water to drink freely, in order to supply the tissues with fluid and keep the mucous membrane of the mouth moist and clean, for all sick patients moisten the lips and tongue frequently. Mouth Washes Commonly Used.—For general purposes the following solutions are satisfactory:—Listerine and water, equal parts: Glycothymolin, one-third strength: Boric acid solution: Dobell's solution, one part in three parts of water or Dobell's solution and listerine, equal parts: Lemon juice and glycerin THE MORNING TOILET 83 equal parts or one dram of lemon juice in three drams of glyc- erin. For a very dry mouth the following arc effective:—Albolene and boric acid, equal parts with a small amount of lemon juice: Listerine, peroxid of hydrogen and lemon juice, equal parts, diluted to one-half strength with water: Glycerin, drams two, lemon juice, drams two, boric acid, ounces two, and water ounces two. When the mouth is dry and the tongue is very coated and dirty, the application of cold cream or liquid albolene ten or fifteen minutes before cleansing will soften and greatly aid in cleansing. When sordes have formed and the mouth is in a bad condi- tion, the following mouth washes are effective:—Dilute hydro- chloric acid, minims fifteen, essence of peppermint, dram one, dilute one-half strength with water: Tincture of myrrh, one part with eleven parts water, or tincture of myrrh, potassium chlo- rate, Dobell's solution, each drams two, and water, ounces four. Glycerin alone is healing but should not be used when the mouth is dry, as it is too astringent. When possible, always use a mouth wash which is pleasant to the taste and agreeable to the patient. Always rinse the mouth well after using an antiseptic mouth wash. Allow the pa- tient to cleanse his own mouth when his condition will permit. Use his own tooth brush when available. A nurse, before cleans- ing the patient's mouth, should see that her hands are scrupu- lously clean. To cleanse the mouth of a very sick patient, remove one pillow and turn the patient's head toward you. Protect the patient and the bed by placing a towel under the chin across the chest. Open the mouth and examine it before and during the procedure. Cleanse all parts thoroughly but use the greatest caution not to break or injure the mucous membrane, as this makes it more liable to infection. Cleanse with the solution or paste on the patient's tooth brush or on gauze wrapped carefully around a tongue depressor or whalebone; use each piece of gauze only once. Avoid making the patient gag; avoid touching the back of the throat. Use a swab (cotton on a tooth pick) for removing particles between the teeth. Allow the patient (if strong enough) to rinse his mouth after cleansing, first with an antiseptic mouth wash, then with water. When the tongue is parched and dry, apply liquid albolene to the tongue with a medicine dropper after cleansing. BRUSHING, COMBING AND BRAIDING THE HAIR The hair should be attended to morning and evening, if pos- sible. Special care should be taken for a very sick patient or during a long illness. The object in the care of the hair is (1) to add to the comfort 84 THE PRINCIPLES AND PRACTICE OF NURSING of the patient; (2) to keep it clean and tidy; (3) to preserve it and keep it free from tangling, etc. In combing or brushing the hair, comb small strands at a time. To prevent pulling and further tangling, hold the strand above the part being combed so that the pull comes on your hand, not on the hair roots, and comb the tangles out from the ends first. Comb gently, but remove all tangles. If the hair, through neglect, carelessness or want of skill, has become snarled or tangled it may be difficult or impossible to disentangle it with- out torturing the patient, and causing injury to the hair. The tangled portion may have to be cut out. Applying vaseline or sweet oil, or wetting the hair with alcohol will help to remove the tangle, but time, patience, and skill are required. This disgrace- ful condition will never occur (except possibly after some acci- dents or operations on the head) if the hair is attended to prop- erly each day. Braid the patient's hair in the way most comfortable to the patient. When she is lying down it is best to part the hair from the brow to the middle of the neck and braid it in two braids, one on each side, so that the head of the patient will not rest upon it. WASHING THE HAIR When an illness is prolonged and the patient has been confined to a bed for a long time, the condition of the scalp and hair be- comes a source of irritation and discomfort. It then becomes necessary to wash the hair with the patient in bed, for cleanli- ness, for comfort, and to preserve the hair. The shampoo may be given with little or no inconvenience to the patient. Method of Procedure.—See that everything required for the procedure is at hand before beginning. Place the patient at the side of the bed in a comfortable and convenient position. Leave the hard pillow only under the head, and place it so that the patient's cheek will rest against it when the head is turned on one side during the treatment. Arrange the patient's gown and the upper bedding so that they will not be in danger of getting wet. Protect the pillow and under portion of the bed with a large rubber, arranging it in the form of a trough so that the water will flow into the receptacle on the floor, and not down the patient's neck, or be absorbed by the clothing. Place a rub- ber dressing sheet across the upper bedclothes and the patient's chest and fasten it securely around the neck. A towel may be placed between the rubber and the patient's skin. A folded towel may be placed under the cheek to protect it from the rubber The towels must not be exposed, however, as they will absorb the water and wet the patient and bedding. Non-absorbent cot- ton may be placed in the ears. The patient should keep her eyes closed during the treatment. In washing the hair use plenty of soap and hot water, and THE MORNING TOILET 85 massage the scalp well. Rinse thoroughly, first with hot, then with cool water and dry as quickly and thoroughly as possible with hot towels, and by rubbing and fanning. Remove the wet things and make the patient comfortable as quickly as possible in order to protect from exhaustion and from getting cold. A small rubber and towel may be placed on the pillow. The hair may be spread on this and the fanning and rubbing continued until it is quite dry. The hair should not be braided until quite dry. THE BATHING OF INFANTS AND YOUNG CHILDREN The bathing of infants will always be assigned to an expe- rienced nurse, because they are so delicate, so sensitive to cold and exposure and so susceptible to infection. They require con- siderable skill in handling, lifting and supporting, in undressing weighing, bathing and dressing quickly and without unnecessary exposure. Their delicate skin and the mucous membranes of the mouth, nose and eyes are so easily irritated and injured in cleansing that they require the most expert care. The impor- tance of the observation of symptoms and the length of time, special training and experience required before one can under- stand little babies and observe the symptoms of disease are other important reasons for assigning the bathing of infants only to an older and more experienced nurse. Probationers may, however, be required to bathe older chil- dren. The bed bath will be much the same as for an adult, giv- ing particular attention to the mouth, buttocks and genitals. Children should be taught very early to clean their teeth prop- erly. The head should be examined carefully for pediculi. The room should be warm; the bath should be given quickly, and the child must not be exposed or chilled during or after the bath. When a tub bath is given, a child should never be left alone. The temperature of the water should be 85° F., the bath should last only a few minutes and should be followed by a cold douche at 70° F., the child standing in the tub. This should be followed with a brisk rubbing until thoroughly dry and warm. Daily baths should be given to all children while in the hos- pital, if possible. They not only promote the child's health, but teach him proper standards and habits of cleanliness which go far toward building up a strong, healthy body. One of the chief duties of the nurse and of the hospital is to teach proper habits of living. Children are very impressionable. Their habits are still to be formed, and they are quick to observe and eager to imitate the habits and standards of those about them. They un- consciously imitate those about them. We cannot prevent them from forming habits, either good or bad, but it is our duty to see that they form only good habits. CHAPTER X FEEDING THE PATIENT The Effect of Food in the Care, Comfort, and Recovery of the Patient.—"The maintenance of vital resistance by proper feeding" is one of the first of the influential factors in the treat- ment of all forms of disease, "often of greater importance than the measures devoted to the treatment of the disease itself." The human body has been compared to a lifeless machine in that both wear out; both need repair; both do work, and both need fuel. In the human body the material for growth and repair, the power to do work and supply heat, can only be sup- plied by food—food is absolutely essential to the maintenance of life. The Kind of Food Required.—1. For growth and repair— protein, which forms one of the chief constituents of meats, eggs, milk and milk preparations such as junket and custard, etc., used in the body to build new tissues and to repair damaged or partly broken down cells. Protein is absolutely essential to the formation of protoplasm, which is the basis of all living things. Gelatin added to broths or desserts and carbohydrates are used as protein sparers, that is, to prevent the breaking down of body tissues. 2. For the power to do work and to supply heat—carbohy- drates and fats are both used in the body to create heat and energy, just as fuel is used in an engine. Carbohydrates are given in the form of cereals, vegetables, fruits, bread, drinks con- taining sugar, broths containing barley, etc. Fats are given in the form of milk, cream, butter and oils, etc. Both may be stored up in the body as reserve fuel capable of being burned up or converted into the heat and energy necessary to maintain life. Heat is necessary to maintain the body temperature at which life or the chemical processes which mean life can be con- ducted, just as we must have heat to produce the chemical changes in meat and other foods which give them their agreeable flavors. Energy is necessary to carry on the life activities or functions which distinguish the living from the dead. Remember that energy is required, therefore fuel must be burned, every time we breathe, or the heart beats, or the eyelids open or close, or a hand is raised, so that if fuel (carbohydrate or fat) is not sup- plied these functions cannot go on. The body simply must have both heat and energy, even at the expense of its own tissues. Protein should be reserved in the 86 FEEDING THE PATIENT 87 body for growth and repair, but if carbohydrate and fat are not supplied or, because of some disorder in the body, cannot be used then the body uses protein as a substitute. This may be the protein given in the food which should be used for growth and repair, or it may be the protein in our own tissue cells; that is, the body gives up its own tissue so that we are gradually con- sumed as fuel in order to create the heat and energy necessary to breathe and make the heart pump the blood around, etc.— Self-preservation is the first law of nature. Now which fuel should we give to the sick—carbohydrate or fat? Always that which is most easily digested and assimilated should be given because the patient's vital powers are low and digestion itself uses up energy. Fats are not easily digested by sick people because they are difficult and require a great deal of energy to burn. Burning or combustion is the chemical process of oxidation, that is, adding sufficient oxygen to break up the compound. Fuels, carbohydrates and fats, both contain a cer- tain amount of carbon, hydrogen, and oxygen. The ease with which they are burned and the amount of heat and energy given off depend upon the amount of carbon present and the amount of oxygen required, that is, upon the relative proportion of car- bon and oxygen. Take, for instance, a simple sugar, glucose, the chemical formula of which is C0H12O6—it is easily seen that little oxygen is needed, that is, it is easily burned. Compare a fat, the chemical formula of which may be C57H110O6 and you will readily see that while the fat, when completely burned, will yield more heat and energy, it will burn more slowly and with more difficulty. Fats must therefore be given sparingly, and when given they must be finely divided. Now if we do not give the patients the proper foods we allow them to starve before our eyes, or if we allow very sick patients to exert themselves unnecessarily we force them to use up energy which should be conserved for the vital processes of breathing and the work of the heart, etc. Certain salts are also essential. Sodium chlorid (the common table salt) is needed chiefly in the fluids of the body to keep up a constant exchange between them and to maintain the same concentration or osmotic pressure. All animals are fond of and require salt. A porcupine, for instance, will gnaw through the thickest beam or floor of a house to obtain salt, and buffaloes will travel miles in droves to reach the "salt licks" for the sake of licking the salt. Other salts and minerals such as potassium, phosphorus, calcium, magnesium and iron, etc., are needed in the tissues themselves in order to carry on their functions. Water is necessary for the chemical changes upon which life depends—it is the universal solvent and substances must be in solution before the chemical changes can take place. Water is a necessary constituent of protoplasm (90 per cent, of proto- plasm or 60 per cent, of the body is water) ; it stimulates the secretions, keeps the mouth moist and in good condition, relieves 88 THE PRINCIPLES AND PRACTICE OF NURSING thirst, aids digestion and elimination, and has a very important influence upon metabolism. Unless fluids arc restricted, the pa- tient should be encouraged to drink plenty of water. The supply must not be left to chance or until the patient complains of thirst. Effect of an Insufficient Supply, Faulty Digestion, or Assimilation of Food.—Anyone who has been very hungry will know the feeling of weakness and lack of energy, the constant nagging sensation of hunger with irritability and inability to pay attention, to concentrate, to study, or to do anything, in fact, even to take an interest in the things usually enjoyed. Again, when suffering from indigestion, how peevish, irritable, heavy and dull one feels. When indigestion becomes chronic the facial expression, the whole mental and moral outlook are changed. One develops the dyspeptic face and disposition, a pessimistic, gloomy, grouchy, ungenerous attitude toward life. One is unable to take a large view, cannot sleep, and one's mind becomes concentrated on oneself, like a growth eating away at body and soul and mind. There is a form of insanity due to starvation and hunger, and a body never properly nourished has a definite relation to crime. Starving people are not entirely responsible for their actions. They may be starving because they have not enough to eat, or because their tissues are unable to assimilate or use the food given them. Patients who are on a "special diet," that is, who are suffering from a disease which makes a restricted diet neces- sary, are always, and very naturally so, difficult to satisfy and they require special patience, tact, and sympathy. Diabetic patients, that is, patients whose tissues are unable to use the sugar supplied them, and so are never satisfied, are most pa- thetic. They have a constant, intolerable craving for food—so great that their morals may become so depraved that they will steal, lie, or do almost anything to obtain food, even though they know it means death. They cannot be trusted because their self-control, will, and all their inhibitions finally become broken down so that they are unable to resist the cravings of their tis- sues. Remember that nearly all forms of illness interfere with digestion, either directly or indirectly, from lack of exercise, poor circulation, or general depression. The Effect of Fever.—The high temperature and the toxins cause increased destruction and wasting of the tissues so that the patient becomes very emaciated. The mouth becomes dry; the appetite and digestion are poor, so that very great care must be taken to keep the mouth in good condition, to stimulate the appetite, to supply food which will be easily digested, and which will nourish and build up the tissues and prevent them from wasting away. They require plenty of water also. For the patients the meals are the chief events of the day the chief events to look forward to so that if they enjoy their meals they are apt to be happy and contented with everything else, so great is the effect on both mind and body. FEEDING THE PATIENT 89 Conditions which Favor the Digestion and Assimilation of Food.—This means not only giving the patients food suitable in quantity and quality, but food which they will be in condition to digest, and not only to digest, but to absorb, distribute and utilize so that it may be converted into new tissue or into heat and energy. We are living in the midst of plenty, but many are poorly nourished. The Condition of the Mind.—Freedom from the emotions of pain, excitement, worry, anxiety, fear, anger, passion, depres- sion, monotony, irritability, nervousness, homesickness or distress of any kind.—It is a well known fact, within the experience of all, that any painful emotion interferes with digestion. Each inhibits the secretions of the body, not only the saliva, gastric juice, intestinal and pancreatic juice necessary for digestion, but the secretion of other glands essential to the working of the body. These glands have been called the drug stores, the chemi- cal reserves of the body, which secrete very powerful substances having a marked effect on every organ in the body. Painful or violent emotions may throw them completely out of gear. Common Expressions Used Indicating the Effect of Painful Emotions.—"White with rage," "frothing at the mouth" with anger; "beads of perspiration," or "in a cold sweat" with fear; the "hair rising" with fear or anger; "don't get your back up" with anger; "the eyes popping out of the head" with excitement, trembling with excitement, fear or nervousness; "the tongue cleaves to the roof of the mouth"; the "heaving chest" with grief or anger; the act of blushing with anger, etc.; "my heart was in my mouth," and many expressions in literature ("Good digestion waits on appetite and health on both"—from Macbeth)—all show that the effect of these emotions on the functions of the body is a matter of common experience. Experiments on animals show that when they are in fear or anger there is no secretion of digestive juices and no contractions of the muscles of the stomach or intestines: All the abdominal viscera are out of commission, so that the food remains stagnant. The result with a person is usually a sick headache, followed by vomiting. The "ordeal of rice"- was a test for crime used in India in which the suspected person was given rice to chew; if it was ejected dry, showing fear, the person was considered guilty. Never give food immediately after excitement, passion, grief, or any of the above conditions. Repeated emotions will make the condition—stagnation of food—chronic. Pleasurable sensations and emotions, however, aid digestion by increasing the secretions and contraction of muscles, and so we have such expressions as "laugh and grow fat," and "joy never kills." In the olden days the beneficial effect of pleasure and laughter on digestion was recognized in the custom of having a jester always present during dinner. Pleasurable companions, bright cheerful surroundings, interesting, witty conversation, laughter, a cheerful frame of mind, the sight, taste, and smell of 90 THE PRINCIPLES AND PRACTICE OF NURSING appetizing food, food well and daintily served, a good appetite and pleasure in eating all favor digestion and assimilation. Eat- ing too much or the sight of too much food will spoil the appe- tite. Unsavory food, unpleasant odors, lack of variety, being obliged to think, to plan or to decide what one will have, all interfere with digestion. Freedom from Excessive Fatigue, Mental or Physical.—The products of fatigue circulate in the blood and have a very de- pressing effect on the nervous system, which inhibits the secre- tions of the body and the contraction of muscles, so that food in the stomach and intestines- will remain stagnant. Experiments on animals show that these results may be obtained in an animal quite fresh and lively, by injecting into it blood drawn from a fatigued animal. This fatigue may be of the body or the mind from overwork, loss of sleep or rest, or fatigue of the senses due to din and noise, confusion, too much reading, talking or needle- work, etc. Freedom from hurry, with regularity and punctuality in serving.—Sick people should be allowed to eat their meals very leisurely. If hurried they become nervous and unable to eat. Also if hurried they are unable to masticate their food properly and so break the first rule of digestion, for digestion means to tear apart. RULES TO BE OBSERVED IN FEEDING PATIENTS 1. See that the patient is properly prepared. Have no un- necessary articles on the bed or table (except flowers). Arrange the pillows, etc., so that the patient will be in a comfortable posi- tion for eating. See that the table and tray are in a convenient position. 2. Remove as far as possible disturbing sights likely to dis- agree with the enjoyment of the food; place a screen around the bed of a patient who is vomiting or who is very ill or dying. 3. Do not serve food directly after a painful dressing or ex- citement. See that all patients are allowed to use the bedpan before, but never during meals unless absolutely necessary. 4. The ward should be quiet and in order during meals and the patients undisturbed by treatments, dressings, visitors, or doctors' rounds. 5. The patients should be alone and unobserved as much as possible. When eating they should not be obliged to talk or be talked to, especially about food. Their minds should not be kept busy or distracted by anything demanding attention. 6. Their appetites should not be spoiled bv hearing food talked about, by seeing or smelling the food of others, by seeing it in the raw state or in bulk when brought in by visitors, or by having more than they can consume. The very'thought of food often makes a patient ill. FEEDING THE PATIENT 91 7. Don't discuss food with the patient. This robs it of the element of surprise and novelty. Don't ask the patient to decide what he will have. This is often an effort, even to well people who enjoy it more if someone else decides for them. 8. Be very strict in giving food according to the doctor's orders, which are based on the patient's condition. The diet is an important part of the treatment and the patient's recovery may depend upon it. It may be a "special diet" in which the amount of protein, carbohydrate, and fat is prescribed, carefully weighed out, and prepared, and the amount taken by the patient estimated and charted. It may be a diet in which certain foods are entirely prohibited: It may be a "salt-free" diet, that is, the patient is allowed nothing containing salt. It may be "starva- tion diet" in which the patient is allowed nothing at all for a certain length of time. It may be a "milk diet"—nothing but milk. It may be "full" or "regular diet"—anything the patient desires. It may be "light diet"—the amount and kinds of meat restricted. It may be "soft diet"—foods very easily digested with fluids in addition. It may be "fluid diet" only—the fluids being given every two hours amounting to from four to six pints per day, and containing the prescribed number of calories which varies with the condition—the normal average man requires 2300 calories when at rest in bed to meet the daily needs of the body. The fluids may be forced as in toxic conditions, rheuma- tism, gout, after a hemorrhage, and in deficient elimination by the kidneys and other diseases; or the fluids may be restricted, as in ascites, dropsy, edema or effusions. Certain tests also may be performed for diagnosis or treatment, in which regulation of the diet is necessary. A nurse must never give anything to the patient, either to drink or eat, without being fully acquainted with the diet that the patient is permitted to have. 9. See that the food is properly cooked and served; that it is not burned or greasy, and that the tray is daintily arranged. 10. Consider the patient's likes and dislikes regarding food and seasoning—does he take tea with or without sugar and milk, for instance? 11. See that the tray is complete, not minus fork, knife, spoon, or seasoning—salt and pepper. Flavors and seasoning have lit- tle nutrition but they are pleasant to the taste and therefore aid digestion. 12. Select food according to the patient's appetite: Give small servings and one thing at a time to tempt the appetite. 13. Use diplomacy, not force, in feeding; coax, encourage, en- tice, tempt the patient. 14. Do not drop or spill things in transit, such as tea in the saucer. 15. Serve meals promptly, especially fluids. The stomach empties itself and demands food regularly. This is illustrated 92 THE PRINCIPLES AND PRACTICE OF NURSING by babies, who invariably cry (if healthy) when it is near feed- ing time. Adults do not cry but nevertheless their stomach and tissues demand food just as insistently. 16. Do not hurry the patient. Give assistance (such as cut- ting meat) when required. 17. Serve hot food on hot dishes—see that the steam table is hot; serve cold food on cold dishes. 18. See that the dishes are clean and whole. 19. Avoid extremes of temperature, rich or highly seasoned foods in gastric disturbances. 20. Be sure that food such as meat, milk or eggs, etc., is always in perfect condition and properly prepared. 21. Never leave food untasted or partly eaten on the stand. The sight, odor, or thought is nauseating to the patient, ruins his appetite, and makes him disgusted with everything. 22. The preparation and administration of fluids, where pa- tients are on fluid diet, require thought, skill, patience, and con- scientiousness. Don't consider your duty done because you offered the patient some fluid you had prepared but which he refused—"didn't care for any." Don't let him starve, die be- fore your eyes for want of food. See that he gets something that he will care for. Give it very slowly. It may be only a teaspoonful every quarter of an hour or every half hour, but don't be satisfied until he gets all of it. Don't chart untruthful, misleading statements; for instance, that the patient has had six ounces of fluid because the cup holds that much, when per- haps he has taken only a few sips of it. He probably would take all of it if given slowly and at a time when he can take it. Study your patient and find out when food seems tempting and desirable to him. Many people enjoy food best after a sleep and the sick can usually take food best after a restful sleep. Don't allow the patient to become so faint and fatigued for want of food that the mere exertion of taking it is too much for him. Give nourishing, stimulating and refreshing fluids at suitable hours; for instance, give stimulating fluids, such as hot coffee, early in the morning when the temperature is normally at its lowest degree showing that life activities are also at their lowest. In the afternoon the body temperature increases due to the di- gestive processes and other activities of the day, and the patient- is apt to be hot, uncomfortable and tired—refreshing drinks are then very acceptable. Stimulating fluids should not be given at night because they prevent sleep. Warm milk may be given but not too hot as all hot fluids are stimulating. Nourishing fluids are given during the day. Do not allow the patient to exert himself. Support his head by placing your hand under his pillow to the opposite shoulder and elevating it. Do not give nourishment directly after some necessary exertion or painful experience—the hot, trembling hands and lips, the dry mouth, and difficulty in swallowing show that the patient is in no condition to digest any food. FEEDING THE PATIENT 93 Be very careful in giving milk to sick people. Give it very slowly, in sips; give a drink of water after it to prevent particles of milk from being caked in the dry mouth. See that the mouth is well rinsed. It must be given slowly so that it will be more finely divided and not form a hard curd in the stomach, difficult to digest. Also see that milk is in perfectly fresh condition and not given so frequently as to create a distaste for it. Milk is a perfect food, highly nourishing and necessary in a liquid diet to secure a sufficient amount of nourishment or number of calories. Milk, even when quite fresh and sweet and kept under the most favorable conditions, contains many bacteria which will multi- ply in the warm stomach and cause fermentation and flatulence if digestion is poor and the milk remains stagnant in the stomach. If the milk is "on the turn," showing that the bacteria have already multiplied and begun the fermenting process, the danger of flatulence is much greater. Flatulence is one of the most dreaded conditions in such diseases as typhoid or pneumonia. Before giving fluids, particularly milk, be sure that the mouth is clean. 23. Note how much the patient has eaten, note what he has eaten and what is not eaten. If he has not eaten a sufficient amount then see that he is given food at another time. 24. Note the effect of the food on the patient—whether it disagrees and causes nausea, flatulence or constipation, etc., or whether he has a distaste for it or not. 25. In feeding a patient use drinking cups or glasses, cup, saucer and spoon or medicine dropper, glass drinking tubes or straw tubes. Never use glass tubes for children or for delirious patients. When a patient is unconscious as in collapse, shock or coma, etc., it may be necessary to feed him by nasal gavage or rectal feedings. Sometimes, however, even though the brain is neither receiving nor sending out messages to the body, he may, with patience, be encouraged to take liquid food with a spoon. The touch of the spoon to the lips or the gentle pressure of the spoon on the tongue or the presence of food in the mouth may be sufficient stimulus to cause the act of swallowing because it is normally a reflex act, that is brought about by the above stimuli without the direction of the brain. (Experiments have shown that animals may be fed in this way even though the brain (the cerebrum) be entirely removed.) Give the liquid very slowly, see that it does not collect in the mouth or return through the nose and watch the patient's color to be sure the food enters the esophagus and not the larynx as this would strangle him. THE FEEDING OF INFANTS AND CHILDREN Nearly all infants in a hospital are on artificial feeding, that is, they are given a substitute for mothers' milk cud are fed from a bottle or with a medicine dropper. The doctor prescribes the feedings. An older nurse prepares 94 THE PRINCIPLES AND PRACTICE OF NURSING them, but a probationer is frequently responsible (under the supervision of the headnurse) for feeding infants and children. The Importance of Proper Feeding.—Nothing is of more importance in the care of an infant than its proper feeding. In- fants and children truly eat to live and not only to live, but to grow and develop until able to care for themselves. They re- quire the same food principles as an adult, but they require relatively a much higher number of calories in order to provide for the important business of growth.' As stated in a previous chapter, during the first year, when the infant trebles his weight, the food requirement is 20 calories during the first month, 35 calories during the second, and 45 calories during the balance of the first year for each pound of body weight. In succeeding years as the gain in weight is relatively not so great the caloric requirement gradually diminishes until at the end of the second year 35 calories per pound of body weight and at the end of ten years 25 calories per pound of body weight are suffi- cient. To be of value the food must not only contain sufficient calo- ries and the food principles in the proper proportions suitable to the infant's digestion, but it must be in the proper form and the amount prescribed for each feeding must be given regularly and by the proper method. Method of Feeding Infants.—No matter how careful the doctor may be in prescribing and the nurse in preparing the feed- ings, the food will be of little value if not given to the baby in the proper way. The following important rules should be ob- served: 1. Feedings must always be given promptly on time, neither five minutes before or after the regular time. Regularity is very important, as it tends to establish regular habits. If asleep, in- fants must be wakened at the regular time. 2. The intervals between feedings are determined by the emptying time of the stomach. During the first and second month, feedings are given every three hours, except at night, at 6, 9, 12, 3, 6, 10 and 2, making seven feedings in all. At the age of three months and after the intervals are longer—6, 10, 2, 6, and 10—making five feedings in all. After three or four months no feeding is given at night between 10 and 6. 3. Infants should always be changed before feedings so that they will be comfortable, not restless during the feeding, and so that they will not have to be disturbed after feedings. Infants may be played with before feedings, but never during or after feedings. Play should be in the form of exercise, that is, allow- ing him to wave his arms and legs about or grasping your fingers and pulling himself up, etc. It rests an infant to take him up before feedings. 4. The food should be at the right temperature—100° F. Care must be taken not to overheat the bottle or the baby might be burned by contact with it. The temperature of the food FEEDING THE PATIENT 95 is tested by shaking some of it on the front of the wrist or back of the hand. 5. The nipples should be removed from the boric acid solu- tion in which they are kept and fitted to the bottle just before giving the feeding. The nurse's hands must be clean. The nip- ples should be handled as little as possible and should not touch anything before being inserted in the infant's mouth. The size of the hole in the nipple and the rate at which the milk flows are very important. It should be large enough to Fig. 1.—Series of X-ray Exposures by Dr. LeWald to Show the Swal- lowing of Air During Feeding and the Method of Getting Rid of It, by Holding the Child Across the Left Shoulder of the Nurse, as Suggested by Dr. C. H. Smith. See Figure 5. Child, aged 4 months; shown also in Figures 2, 3 and 4. One-half ounce of feeding was taken in the first two minutes. Plate taken five min- utes after the feeding was begun. Note the small amount of milk in the stomach with a small bubble of gas anterior to it. There is much gas in the small intestine. G indicates gas in small intestine. A " air in stomach. M " milk. allow the fluid to drop without shaking the bottle. It is better to have the hole a little too large than too small, but the flow must never be more rapid than the infant can comfortably stand. A small hole irritates an infant, uses up energy, wears him out before he has had enough food to satisfy his hunger, and also causes him to swallow air in sucking. Loss of energy is particu- larly to be avoided with weak infants. A hole of the right size may be made by puncturing the nipple with a heated needle. 6. The position of the infant is very important. The head and chest should always be higher than the abdomen so that if 96 THE PRINCIPLES AND PRACTICE OF NURSING air is swallowed or gas forms in the stomach it will collect at the cardiac opening or entrance to the stomach so that it can be belched up without the expulsion and loss of the feeding. In- fants should always be taken up, if possible, during feedings. Care must be taken that they are properly protected from ex- posure and cold. The accompanying illustrations show the effect of position on the collection and eructation of air and gas in the stomach. If each infant cannot be taken up during the feeding, he should be turned on his side in a comfortable position. The head of the crib may be raised a little, or the head and chest of the infant Fig. 2.—The Child Was Then Given 3 Ounces More Food. Child seemed in pain, cried and regurgitated a small amount. Note the large amount of air which has been swallowed, distending the stomach. A indicates air. M indicates milk. may be raised on a pillow. If the bottle is placed on a frame it must be securely fastened in place so that the infant sucks milk and not air. The position of the bottle must be altered as the level of the milk changes. 7. Infants should be closely watched during feedings to see that they are taking the food properly. If active or restless, or if their attention is distracted, even a slight movement of the head may displace the nipple from the baby's mouth so that he cannot get it again. The bottle may be displaced, the nipple soiled, the milk drop on the infant's gown, around his neck, or in his ear, etc. If the flow is faster than the infant can manage the milk will run from his mouth to his gown, etc. In such cases it is difficult to tell whether the wet gown is due to regurgita- FEEDING THE PATIENT 97 tion (simple overflowing from the stomach) or to the belching or eructation of gas and food from the stomach, or to the above causes. 8. The duration of the feeding should be from ten to twenty minutes. It is better to err on the short side. An infant must not be allowed to nurse slowly. He must be kept at it and not allowed to go to sleep. It is important that he gets all the food Fig. 3.—Thirty Minutes After Feeding Was Begun. Erect position. Milk (M) has gravitated to the lower part of the stomach, forcing air (A) to the upper part. After this the child was held in the upright position as shown in Figure 5. There was a large eructation of gas. The child at once stopped crying and went to sleep. that is ordered. Don't play with him or distract his attention. A prolonged time in feeding tends to air swallowing. Air swal- lowing fills the stomach before the infant has enough food, causes pain, discomfort, irritability, and distaste for the food. Regurgi- tation, eructations, vomiting and loss of weight follow. If the feeding is prolonged also the food becomes cold and is apt to cause colic. 98 THE PRINCIPLES AND PRACTICE OF NURSING 9. While feeding an infant if regurgitation occurs before enough food has been taken to fill the stomach, it is probably due to air or gas. The stomach must be relieved before more food can be given. Support him in the sitting position or hold him over your shoulder and lightly pat his back to aid in the ex- pulsion of the air. The benefit of this may be seen in the x-ray plates shown in figures 3 and 4. Fig. 4.—After Eructation of Gas Observed in Figure 3. Note the stom- ach has become normal in size and shows only a small air (A) bubble which is always present. The child then became free from pain and stopped crying. 10. After feedings an infant should be raised gently and held over your shoulder and his back should be patted until all air has been expelled. He should then be placed quietly and gently in his crib, the head of which should be elevated. Never rock or play with an infant after feedings. He should go to sleep. 11. Chart the amount of food taken. Note the amount of re- gurgitation, if any. Note also the symptoms and signs of im- proper or insufficient feeding. Improper feeding may be indicated FEEDING THE PATIENT 99 by a distaste for food, belching or eructations, vomiting, crying, colic, flatulence, diarrhea, or constipation, the character of the stools, fever, wakefulness and fretfulness. Other symptoms and signs are pallor, anemia and a failure to gain or a loss in weight. Failure to gain weight in an infant is equivalent to loss of weight in an adult. 12. Nipples and bottles should be put to soak in cold water Fig. 5.—Proper Position in Which an Infant Should Be Held After Feeding. Air is swallowed with food by all infants. See Figures 1, 2 and 3. Immediately after feeding, the infant should be held up against the shoulder of the mother or nurse to encourage the eructation of the swallowed air (Smith and LeWald). immediately. Nipples are boiled daily and kept in boric acid solution until used. Bottles are washed with soap, hot water, and a brush and sterilized by boiling before use. 13. Water should always be given to infants between feed- ings. They sometimes cry, not because hungry but because they are thirsty. Lack of sufficient water prevents heat elimination through perspiration. As explained orevicusly in this chapter 100 THE PRINCIPLES AND PRACTICE OF NURSING there is a very definite relation between the fluid balance in the body and fever. Fever may be caused by depriving the system of water, showing its importance in the proper metabolism and functioning of the body. 14. Finger sucking must be prevented at all times, as it causes air swallowing. The Feeding of Premature Babies.—The feeding of a prema- ture baby is usually the responsibility of an older nurse, as these babies require the most expert care. They are very weak and fragile and extremely sensitive to cold. Their powers of produc- ing heat are very poor and they also radiate relatively more heat than larger babies, because their body surface (as is that of all small animals) is relatively greater for their size or volume than that of larger infants or children. Their temperature is therefore subnormal and as the body cannot live with a constant subnor- mal temperature, premature babies must constantly be surround- ed with heat. During feedings they should never be removed from the source of heat. They are usually too weak to take feedings from a bottle, so are fed with a medicine dropper. Diet During the Second and After Years of Childhood.— In artificially fed infants many doctors begin to add semi-solid food at the seventh, eighth or ninth months. The tendency to- day, however, is to begin to add semi-solid food after the fifth or sixth months. Orange juice having been begun at early in- fancy, at about the fifth month small amounts of well cooked cereals such as farina, cream of wheat, wheatena, and others of choice are added to the diet. As the child becomes accustomed to feed from a spoon or cup a new article of diet may be added each few days until by the end of the first year or when the infant weighs 20 pounds the entire list of foods prescribed for the first year is completed. This list usually includes the following articles of diet: milk, orange juice, well cooked cereals, zwie- back, toast, stale bread, graham crackers, coddled, soft-boiled or poached egg, baked or mashed potato with beef juice, well cooked rice, spinach, peas or carrots well cooked and passed through a sieve, junket, custard, cornstarch and stewed prunes. Boiled water should be given between feedings. Between the ages of two and six other solids are gradually added to the list. These consist of meats such as chops, beef- steak, chicken, fish and bacon; vegetables such as squash, string beans or cauliflower, and desserts such as rice or bread pudding, stewed fruit and ice cream. Never give children the following articles: tea, coffee, fried foods of any kind, fresh bread, cake, pie, fried cakes or rich puddings, pork, veal, kidneys, greasy stews or gravy, corn, cab- bage, cucumbers, nuts, raisins, bananas, sugar, sweet preserves or candy, except a small amount at meals as dessert. The Proper Method of Feeding.—The proper method of feed- ing is quite as important during childhood as during infancy. The proper selectiont and preparation of food, the total number FEEDING THE PATIENT 101 of calories, the amount at each meal, the intervals between meals, the duration of the meal and acquiring proper habits of eating are all equally important. The growth and development of the child, his resistance to disease and his general health not only during infancy and childhood but throughout his whole life de- pend to a large extent on proper feeding and the acquiring of proper habits in childhood. The following rules should always be observed: 1. A child should always have his face and hands washed and his hair brushed before meals. The bed and surroundings, and the child himself, should be neat and clean and the room should be quiet and orderly. Clothing should be protected with napkins. 2. A nurse should always supervise the serving of meals. As in serving adults the food should be served promptly in the proper proportions, and made as attractive as possible. 3. The child should be taught to eat slowly, to chew the food well and to eat neatly. No child is too young to learn good manners. 4. He should be made to eat the food provided and should be allowed to go hungry if he will not eat the proper food. 5. He should not be allowed to eat between meals. Food brought by relatives should be given only at meal time. 6. Water should be given freely between meals, but little should be allowed at meals. The child's tendency is to wash the food down with water or milk without proper mastication. 7. Children should always rest for half an hour after meals. CHAPTER XI THE ELIMINATION OF BODY WASTES "The elimination of effete materials by the kidneys, bowels and skin" is one of the most influential factors in the treatment of all forms of disease, "often of greater importance than the measures devoted to the treatment of the disease itself." As seen in the previous chapter the health, life and efficiency of the body depend upon the digestion and assimilation of the proper kind of food. But equally important is the elimination from the body of the ashes which remain—the ashes of the ex- cess food we eat which the tissues do not need or cannot use, and the waste products of metabolism together with other poisonous products of metabolism and disease. These wastes, if allowed to remain, would clog and poison the whole system. The kidneys and the bowels are the most important excretory organs. In any disease, if the kidneys can be kept actively working and the bowels "kept open" so that the waste and poi- sons are eliminated as fast as formed, the cells can put up a good fight so that the patient has a good chance of recovery. If either one fails to do its work, the whole body will suffer and be clogged up so that the little cells, choked and poisoned by their own excretions, will fail to carry on their work. In sickness the nor- mal wastes of metabolism will be increased by the products of the disease and these wastes may be so irritating and poisonous or so great in amount that the kidneys become overworked, irri- tated, inflamed and diseased themselves, so that they also break down. This condition is very serious so it is important to watch how the kidneys are working by examinations of the urine. Again, the other organs of the body may be normal, but the kidneys or bowels may be diseased and so fail to excrete even the normal wastes of metabolism or digestion. These wastes must then accumulate and every organ in the body will suffer so that in all cases it is extremely important to note whether the normal quantity and quality of urine and feces are being elimi- nated. A nurse must therefore never fail to note the number quantity, and character of the eliminations from the bowels and kidneys. She should never empty a bedpan without first find- ing out whether the urine is to be measured and charted, whether it is to be sent for examination, whether all the urine voided is to be saved for examination, and whether or not a specimen of the stool is to be saved for examination. The diagnosis treat- ment, and recovery of the patient may depend upon it. 102 THE ELIMINATION OF BODY WASTES 103 THE ELIMINATION OF WASTE PRODUCTS FROM THE INTESTINES The Importance of Regularity in Defecation.—Constipation, or failure of the bowels to eliminate waste matter, is a very com- mon condition, largely responsible for many ills from which the body suffers. Lack of regularity in going to stool at a definite time each day is the most common cause of constipation. As explained in the following chapter, the presence of feces in the rectum normally causes a desire to expel it, a desire which in a healthy bowel must be responded to. If this desire is ignored repeatedly, feces may collect in the rectum and colon without causing any desire to expel it and soon the power to do so is lost. Constipation is the result. Forming the habit of going to stool regularly at a definite time each day is the only permanent cure for constipation. A patient who enters the hospital may or may not have formed this habit. If he has formed the habit, a nurse must see that no neglect on her part shall interfere with this important function for in doing so she would cause the patient an injury from which he might be a long time in recovering. If he has not already formed this habit, a nurse can do a great deal in helping him to do so while in the hospital. Regularity in voiding urine is also important. To preserve or develop this habit, bedpans must be given at regular intervals. With the majority of people the desire to go to stool is felt immediately or shortly after breakfast. Whether the patient desires it or not the bedpan should be given at this time, and an attempt be made to use it. The desire to void urine is felt at more frequent intervals. For this purpose the bedpan or urinal should be given before bedtime, on awakening in the morn- ing, and after each meal. Except under unusual conditions, for instance, when the patient has had a cathartic or has diarrhea or some disease of the urinary tract, which makes frequent void- ing a necessity, bedpans should not be given at irregular hours. Every consideration should be shown the patient, however, under the conditions mentioned. If this rule is observed, it will not only be of invaluable benefit to the patient both as regards his present comfort and future health, but will make the work of the ward run more smoothly and efficiently. It will make the use of the bedpan unnecessary during meals, visiting hours, "doctors' rounds" and at other undesirable and awkward moments. Method of Giving a Bedpan to a Patient.—When giving a bedpan the following rules should be observed: While no false modesty should be shown in regard to the normal and necessary functions of the body, a bedpan should always be properly cov- ered and carried to and from the patient as unobtrusively as pos- sible. The bed should be screened. The bedpan should be warm and should be placed gently under the patient in the proper posi- 104 THE PRINCIPLES AND PRACTICE OF NURSING tion. A bedpan with enamel chipped off should not be used, on account of the danger of injuring the skin. If necessary to use a chipped bedpan, it should be protected with a pad. A pad should always be used when the skin is tender and in danger of bruising or breaking. In placing the bedpan, if the patient requires assistance, direct her to draw her knees up and to press her heels against the bed. At the same time, slip your left hand under the pelvis, raise the hips, place the bedpan in the proper position, and gently lower her on it. When the bedpan is in use see that the cover is not thrown on top of the bed, table or chair, but place it on the bar of the bed under the bedclothes out of sight, so that the patient need not be embarrassed should someone come behind the screen. Leave the patient alone unless she is very ill or weak and apt to faint or become exhausted. Do not leave the patient longer than necessary on the bedpan. In removing the bedpan, support the patient as before. Turn her on her right side. Cover the bedpan immediately. If the patient is able to complete the toilet, see that toilet paper, basin of water, and cotton pledgets are at hand and placed conven- iently. The patient should be allowed to wash her hands after- wards if desired. If the patient is unable to do this satisfactorily and without fatigue, the nurse must do it for her. The bedpan should be removed as soon as possible and washed first with cold running water, then mopped and scalded with hot running water. Chloride of lime is used as a deodorant in the pan and hopper if necessary. What to Observe about the Feces.—The principal points to be observed in regard to the stools are the number of movements in twenty-four hours, and whether accompanied by pain or straining; the consistency, shape, color, and odor of the stool, and the presence of unusual matter. The expulsion of gas or flatus should always be noted. Number.—There should always be one satisfactory daily movement; with some, two daily movements are normal. When this does not take place it means that waste products are being allowed to accumulate in the intestines. The stool should be formed, but not hard, and moulded to the shape and size of the rectum. When the stool is in small, dark, hard masses it indi- cates that the feces have been impacted for some time in the bowel, allowing water to be absorbed, making them hard and dark and difficult to pass. This indicates constipation. When the stool is fluid it indicates that there is irritating matter in the intestines which causes them to contract and empty themselves quickly and frequently, so that the contents do not remain long enough to allow the water to be absorbed forming the normal solid, moulded stool. This may indicate diarrhea, or it may indicate constipation, the irritation being caused by the hard im- pacted feces on the lining of the intestines. Any alteration in the shape or size of a formed stool should be noted, as it may in- THE ELIMINATION OF BODY WASTES 105 dicate a stricture or obstruction of the intestines, due possibly to the presence of a tumor, such as carcinoma. The color of feces is normally a greenish brown, due chiefly to the coloring matter in the bile. Bile is secreted by the liver and flows into the small intestines during digestion. If the stools are pale or "clay-colored" it indicates an absence of bile. This is a serious condition because it indicates either that the liver is not secreting bile, or that there is some obstruction to its passage into the intestines. In that case it would pass into the blood stream and the patient would be jaundiced. Light colored stools may also be due to the presence of undigested fat. When the stool is dark and of a "tarry" consistency, one suspects the pres- ence of blood which has remained in the intestines long enough to be partly digested. Digested blood means that the red cells in the blood have been broken up, setting free the hemoglobin, which in turn is broken up, setting free hematin, a brownish col- oring matter which gives the stool a very dark color. A dark, tarry stool therefore indicates that a hemorrhage into the intes- tines occurred some time previously, and that it probably oc- curred high up in the intestines, or that it came from the stomach where digestion is taking place. Bright red blood in the stool indicates either a very recent hemorrhage or one from the lower portion of the intestines where there is no digestion. Blood com- ing from the lower bowel will be on the surface of the stool, while blood from the stomach or small intestines will be mixed through- out the stool. The color and odor of the stool vary with the different foods eaten, and are also altered by various drugs which may be taken. For instance, a green color may be due to the chlorophyl from vegetables. Iron and bismuth preparations turn the stools black, while calomel turns them to a greenish color. The odor of the stool, as a rule, has no particular significance but an unusual odor should be noted. It may be due to drugs, but is usually the result of putrefaction of protein in the accumu- lated feces in the intestines resulting from constipation. The feces will be dark in color. Gas expelled should always be noted. Gas results from tiie fermentation of carbohydrates in the accumulated feces. The feces will be light in color and acid in reaction. The presence of unusual matter—blood, pus, mucus, worms, etc.—should also be noted and reported. The presence of mucus indicates irritation or inflammation of the mucous lining of the intestine—irritation of any mucous membrane results in increased secretion of mucus. The process in the intestines is the same as that in the nose or throat and the secretion will have the same characteristics as the secretions from the nose with a "cold in the head," or as the phlegm from the throat. Mucus in the stool gives it a slimy appearance. When the inflammation is in the small intestines, where digestion and peristalsis are active, the mucus will be mixed with the stool. 106 THE PRINCIPLES AND PRACTICE OF NURSING When the irritation is in the colon, the mucus will be on the surface of the stool. In severe forms of inflammation, as in dysentery, the stool may consist of nothing but mucus and blood and is accompanied with severe pain and tenesmus. The presence of mucus should always be reported as the con- dition may become very serious and very difficult to cure. Blood in the stools (or in any discharge from the body) should always be looked upon as a matter of the gravest importance. It may be due to a slight irritation from straining in constipa- tion and hard, fecal matter, but it may indicate a very severe irritation or inflammation of the intestines, ulceration,—gastric, duodenal or typhoid ulcers,—carcinoma of the rectum, hemor- rhoids, or diseases resulting in hemorrhages into the mucous membranes, such as scurvy, leukemia, and purpura, etc. The color of the blood, whether on the surface or mixed throughout the stool, whether passed with or after the stool, whether accompanied by pain or straining, and the amount should be noted and charted. It must not be confused with blood from the vagina in menstruation. Pus in the stool is the result of severe inflammation in the intestines, liver or pancreas, with suppuration, or it may be due to the rupture of an abscess into the intestinal tract. Intestinal Parasites.—The intestinal parasites most commonly found in the stools are the pin-worm or thread-worm (oxyurti vermicularis), the round-worms (Ascaris lumbricoides), the amoeba, the hookworm, and the various tapeworms. The pin-worm or thread-worm occurs very commonly in the rectum and colon. Its presence causes itching, irritation, rest- lessness, loss of sleep and appetite, and finally, anemia. It ap- pears in the stools as fine threads usually moving actively. The round-worms are very common intestinal parasites occur- ring chiefly in children. They cause restlessness, irritability, twitchings, and convulsions. They are easily recognized in the stool. Prophylaxis.—When either pin-worms or round-worms are found in the stools, the greatest precautions must be taken to prevent spreading the infection to others and also to prevent the patient (usually a child) from re-infecting himself by contami- nating his hands. They enter through the mouth. The anus and surrounding parts must be carefully washed and also the hands of both patient and nurse. Infected persons should never be allowed to handle foods. The amoeba is the cause of amoebic or tropical dysentery re- sulting in severe inflammation and ulceration of the intestines and abscesses in the liver. The stools contain the amoeba and so are highly infectious. Strict precautions must be taken to prevent the spread of the infection. The amoeba is a one-celled organism which can only be seen under the microscope. Tapeworms.—These are taken into the alimentary tract in in- fected pork or beef, etc., which has not been thoroughly cooked. THE ELIMINATION OF BODY WASTES 107 They lodge in the intestines and cause pain, nausea, diarrhea, and anemia, and give the patient much anxiety and worry. They may be from five to twenty feet or more in length. Segments may be passed frequently in the stool, but as long as the head remains the worm will continue to grow. When treatments are given, therefore, to expel the tapeworm, a nurse must look par- ticularly for the head, which is very minute, about the size of a pin's head, with a very fine neck like a thread. It is difficult to find—several feet of segments may be passed at different times without the head, but this does not relieve the condition. Prophylaxis.—All segments should be burned and never thrown into the closet. When the stool is to be examined for a tape- worm it should be received in a bedpan containing water at body temperature. Look for the head. Some doctors advise that the patient should sit on a commode containing steaming water as hot as he can stand. It is said that this furthers the expulsion of the worm. When a stool has an unusual appearance, indicating the pres- ence of mucus, blood or pus, etc., it should be saved undisturbed for inspection by the doctor, who will decide whether a specimen should be sent to the laboratory for further examination or not. In any case, when it is suspected that the stool contains any ab- normal substance, parasites or blood, etc., and an examination will aid in the diagnosis, a specimen will be required for exami- nation. Usually only a small amount is required, but some- times it is necessary to save the whole amount undisturbed. The Collection of a Specimen of Feces.—When a specimen of feces is to be sent to the laboratory for examination, it should be placed in a clean, proper receptacle which will allow no leak- age. Too much must not be placed in the receptacle, which might allow it to contaminate the cover or the sides, or cause it to spill in transit. It should be properly covered and labelled with the name of the ward, the patient's name, the date, and the tag should indicate the hour at which the stool was passed and for what the specimen is to be examined. Stools should always be sent to the laboratory when quite fresh. When the stool is to be examined under the microscope for amoeba or other.protozoa, it should be sent while quite fresh and warm. It must be exam- ined while warm, because the parasites can only be detected by their movements and cold checks their movements. When stools are collected and sent to be examined for bacteria, such as the typhoid, tubercle, or cholera bacillus, the greatest precaution must be taken to prevent spilling in transit, or contamination of the cover or outside of the container which would endanger the person who handled it in examination of the stool. The recep- tacle should be sterilized, before use, by boiling—no disinfectant should ever be used in the receptacle or mixed with a stool re- quired for examination. Charting.—The number of movements daily is recorded on the chart as long as the patient remains in the hospital. Any 108 THE PRINCIPLES AND PRACTICE OF NURSING abnormality in the character of the movement is also charted. A specimen sent to the laboratory is recorded. When the number or character of the stools indicate that body wastes are not being properly eliminated, or that the intestines are diseased, enemata are usually ordered to relieve the condi- tion. ENEMATA Enemata are among the treatments usually included in the duties assigned to a probationer. An enema or clyster is an injection of fluid into the rectum. Purposes of the Treatment.— (1) If the number or character of the stools indicates that waste products are not being elimi- nated properly, the doctor may order a cathartic or a cleansing enema to be administered. (2) When abnormal matter in the stools indicates a diseased condition of the intestines local, reme- dial applications may be made by means of rectal injections. (3) Medications, fluids or nourishment may also be given by rectal injections to produce a general effect on the whole system. The kind, amount and temperature of the solution used and the method of giving the treatment will vary according to the purpose for which it is given. THE CLEANSING OR EVACUATING ENEMA OR CLYSTER The word clyster comes from a Greek word klysis, which means a washing out of stagnant or waste materials in any cavity (or in the blood) by means of injections of fluid. The Causes and Results of the Accumulation of Feces.— Feces consist of undigested food, intestinal secretions, shreds of mucous lining and bacteria—one-third of the bulk of feces is bacteria. Normally the rectum is empty and when fecal matter is passed into it from the colon, the desire to expel it is instantly felt, for "the rectum is not properly a reservoir for feces, and in the healthy condition the presence of the latter stimulates it to contract" (Woolsey). This is because the nerve endings (the sentinels on guard to warn of danger and guard from injury) if not too dull and depressed, immediately send a message of pres- sure or irritation along the nerves to their cells or centers in the spinal cord, which in turn send a message back by other nerves to the nerve endings in the muscles of the rectum, which causes them to contract and expel the substance causing the irritation or pressure. If for any reason this desire is ignored or neglected frequently, the nerve endings lose their sensitiveness, fail to play their part as sentinels, and large amounts of feces may collect without any desire being felt to express them. Also, from lack of use and other causes, muscles may lose their tone or the con- tinued pressure and distention with fecal matter and gases may paralyze them so that they become unable to contract with suffi- THE ELIMINATION OF BODY WASTES 109 cient force to expel the feces when the desire is felt. The accumu- lated mass in the colon, laden with bacteria, ferments and putre- fies, with the formation of gases and toxic products which are constantly being absorbed and so poison the whole system. This is called auto- or self-intoxication. The result is headache, loss of appetite, mental dullness, and a general feeling of lack of fitness. The purpose of the treatment is to soften hardened fecal matter and to remove any fermenting, putrefying matter, to- gether with toxic substances and gases which may have accumu- lated in the rectum and lower colon, and to do this with the least possible physical and mental discomfort to the patient. The removal of the hardened, accumulated mass may be ac- complished in several ways: 1. By Mechanical Means:— (a) Softening and disintegrating it by the use of softening agents—water, soapsuds, glycerin, olive oil, ox gall and normal saline solution, etc. Glycerin, when used, aids the penetration of water and so increases its softening effect. (b) By using a large amount of water and so distending the rectum and colon. This mechanical pressure stimulates the nerve endings to such an extent by a reflex action that the muscles are forced to contract to expel it. 2. By Physical Means:—Using a hot (or cold) solution which stimulates the nerve endings and reflexly stimulates peri- stalsis. 3. By Chemical Means:—Using irritating substances, such as soapsuds, turpentine, etc. Varieties of Cleansing Enemata:— 1. Simple Soapsuds Enema.—A mild soapsuds solution is made by dissolving a slightly irritating soap, such as castile or ivory, in hot water. All froth or air bubbles should be removed to avoid the entrance of air into the intestines as this would cause pain and interference with the injection of the solution. From two to three pints of this solution are usually used for an adult and from one to one and one-half for a child. More than this should not be used without a doctor's order on account of the danger of over-distention of the intestine and injury to its walls. The temperature should be from 106° to 110° F. The enema is not to be retained. Its effect is due to the mild irri- tation of the soap and the pressure due to the large volume of water. 2. Oil Enema.—Before giving a soapsuds enema, an injec- tion of oil is sometimes necessary in constipation to soften hard masses of feces. Oil enemata are, also, frequently given before the first bowel movement after operations on the rectum or perineum such as for hemorrhoids or a perineorihaphy, in order to avoid straining and injury to the sutures and wound. The enema may consist of six ounces of olive oil, or to this may 110 THE PRINCIPLES AND PRACTICE OF NURSING be added two ounces each of castor oil and glycerin, to aid the softening effect. The oil is prepared by warming it to a tem- perature of 90° F. An oil enema should be retained. It may be followed in one hour by a soapsuds enema or it may be retained from two to six hours before the soapsuds enema is given. 3. Medicated Purgative Enemata.—In obstinate constipation rectal injections of various cathartics may be necessary to hasten or to cause free evacuation. The cathartics commonly used are glycerin, fel bovis or ox gall, Rochelle Salts and Epsom Salts (Magnesium Sulphate). Glycerine and ox gall both act as soft- ening agents on hard fecal masses and by their irritating effect on the mucous lining tend to. cause peristalsis and evacuation. The amount ordered (usually from two to four drams of glycer- in or ox gall) may be added to a soapsuds enema or may be given in a small amount of warm water or normal saline solu- tion and followed in one hour by a soapsuds enema. The saline cathartics, Rochelle and Epsom Salts, may be given in a dilute or concentrated form. From four to six ounces of Rochelle Salts or from one-half to four ounces of Magnesium Sulphate are the usual amounts prescribed for rectal injections. To prepare the solution the amount ordered is added to sufficient hot water to dissolve the salts thoroughly. When given in this concentrated form the concentration of salts in the intestines is greater than that in the blood and tissues. Fluid is, therefore, drawn from the blood and tissues by osmosis in order to dilute the salts in the intestines and render the concentration equal. The resulting accumulation of fluid in the intestines causes pres- sure which induces peristalsis and free evacuations. The saline cathartics are sometimes given in dilute form by adding the amount ordered, first thoroughly dissolved in hot water, to a soapsuds enema. When given in this dilute form the concentration of salts in the intestines is less than that in the blood and tissues, the salts are not absorbed but they prevent the absorption of the water so that the intestines become distended with fluid causing pressure, peristalsis and evacuation. Rectal injections of the saline cathartics are particularly valu- able in nephritis and some cardiac conditions when there is an accumulation of fluid in the tissues (edema). 4. Normal Saline Enemata.—A rectal injection of normal saline has the same cleansing effect on the mucous lining of the intestines as a throat gargle or irrigation with the same solution has on an inflamed throat. It removes mucus and pus and in the intestines dilutes and removes the poisonous products of putrefaction. A normal saline solution when used for a rectal injection is prepared by adding 1 dram of salt to a pint of water. While these proportions are accurate enough when the solution is given by rectum it is not, strictly speaking, normal saline (9-10 of 1 per cent.) and would never be used when the solution is to be injected directly into the tissues (hypodermoclysis) or into the THE ELIMINATION OF BODY WASTES 111 bloodstream (intravenous). When the treatment is given for its cleansing effect two pints of the solution are generally used. It is not to be retained. 5. Carminative Enemata are given to prevent or relieve dis- tention. A carminative enema is an injection into the rectum, of a solution containing drugs which have a carminative action. Such drugs by their antiseptic action prevent the formation of gases and by their irritant action on the nerve endings in the lining of the intestines, cause the contraction of their muscular walls (reflex action) and the expulsion of the gas causing the distention. Turpentine, asafetida, and alum are the drugs com- monly used as in the following: (a) Turpentine.—Four drams of turpentine may be added to two pints of soapsuds. The turpentine must be very thoroughly mixed and dissolved. This enema is not to be retained. (b) Turpentine and Oil.—One-half to one ounce of turpentine may be mixed with six to eight ounces of olive oil. Turpentine is very irritating. The oil is used to dilute and lessen the irri- tation and danger of blistering. To prepare the enema the oil is first heated to about 110° F., the turpentine is then added and thoroughly mixed with the oil. This enema should be retained if possible from one-half to one hour. A soapsuds enema is then given. (c) Alum.—Two ounces of alum dissolved in two pints of hot water. The enema is not to be retained. (d) Compound Medicated.—Turpentine four drams, asafet- ida two drams, ox gall four drams, glycerin four ounces with two pints of soapsuds. To prepare the enema first mix. the ox gall, if in crystals, with the turpentine, otherwise it will not dis- solve. Also see that the utensils used are dry. Add the other ingredients and thoroughly mix with the soapsuds. The temper- ature of the solution when given should be 116° to 118° F. (e) Milk and Molasses.—To prepare the enema heat eight ounces of milk. To this add slowly eight ounces of molasses, stirring it in well. The temperature of the solution when given should be from 100° to 105° F. The carminative action is due to the fact that the sugar in the molasses is irritating to the lining of the intestines and the sugar and milk together produce gas which distends the intestines, causes pressure, peristalsis and evacuation. Rectal injections for a carminative effect are usually given as hot as the patient can stand, 116° to 118° F., the heat being a powerful stimulus to peristalsis and expulsion of the gas. The injections should be given slowly and when small amounts are used, the patient should be encouraged to retain it for from ten to thirty minutes. As the.treatment is given for the relief of distention, note and chart particularly the amount of flatus expelled in the return. 112 THE PRINCIPLES AND PRACTICE OF NURSING LOCAL REMEDIAL APPLICATIONS The following enemata are used when it is desired to make direct application to the diseased wall of the intestine. An Anthelmintic enema is an injection of a solution contain- ing a drug capable of destroying or expelling worms from the intestines. Pin-, thread-, or seat-worms may be destroyed and expelled by repeated injections of the infusion of quassia. About one- half pint is the amount usually used and the treatment is given daily until the worms are destroyed. Before giving the treat- ment the bowel should be cleansed by a soapsuds enema so that the solution may come in direct contact with the worms and the lining of the intestines. Quassia is an astringent. It contracts the tissues and blood vessels, checks bleeding and inflammation, lessens the amount of mucus in which the worms may lodge, shrivels and destroys the worms. The patient should be encour- aged to retain the solution for from fifteen to thirty minutes. Other astringents such as tannic acid or alum (30 grains in one pint of water) are sometimes used to destroy worms, or germs in dysentery or cholera, etc., and to relieve inflammation. They are usually given in the form of rectal or colon irrigations, the solution being allowed to run in very slowly and gently and to return immediately in order to avoid distention, pain and irritation of the inflamed wall. An Emollient enema is an injection of some bland solution for the purpose of checking diarrhea or soothing and relieving irritation of an inflamed mucous membrane. Starch is commonly used. To prepare the solution, dissolve one teaspoonful of starch in a little cold water making a smooth paste. Then add slowly six ounces of boiling water, stirring constantly. Allow the solu- tion to cool to 105° or 106° F. and give with a catheter. The enema is to be retained. Laudanum (tincture of opium) is some- times added to a starch enema to check secretions and peristalsis and to relieve pain and local irritation in diarrhea. When ordered, laudanum should be added just before the enema is given. Be sure that the full amount ordered is given. To insure this sometimes the drug is added to a small portion of the starch. After this is injected the remaining solution is given. ENEMATA GIVEN FOR A GENERAL SYSTEMIC EFFECT When for any reason it is impossible or undesirable to give fluids, medications or nourishment by mouth or when it is neces- sary to supplement the amount given, they may be administered by rectum. The purpose of the treatment may be to act as a general stimulant in shock or collapse; to supply sedative drugs to pre- vent or relieve convulsions; to supply fluid to the body and THE ELIMINATION OF BODY WASTES 113 relieve thirst following a critical operation or severe hemorrhage; or to supply nourishment in the hope that a sufficient amount may be absorbed to sustain the life of the patient. It will be seen that patients receiving such treatments are frequently in a critical condition requiring the most expert care. They are, therefore, usually assigned to an older nurse and will be dis- cussed later. The Procedure.—Factors Which Govern the Method.—When giving a rectal injection it is important to remember the follow- ing anatomical, physical, and physiological factors: The word rectum means straight. The rectum in the infant is straight and vertical. In the adult it is a curved tube about 5 to 8 inches long, beginning at the anus, extending upward and forward into the pelvis to the tip of the coccyx, then curving upward and backward, following the curve of the coccyx and sacrum upon which it lies. It then curves to the left to form the beginning of the sigmoid loop or colon leading to the descend- ing colon. A rectal tube cannot be passed beyond the sigmoid loop under normal conditions. The upper pelvic portion of the rectum is very distensible—large enough to contain the entire hand (Woolsey), so that large masses of feces may accumulate here, and as the water is absorbed these harden and become difficult to remove or expel. The rectum is guarded by two sphincter muscles and, in health, is tightly closed. About three inches up from the anus the mucous lining of the rectum extends out into the canal, forming three folds, acting as valves or ledges (Houston's folds or valves), which probably support the feces and so relieve strain on the sphincters of the anus. These are more prominent when the rectum is distended with feces, etc. They must be remembered when passing the rectal tube because they may interfere with its passage, espe- cially when the rectum is empty. Never force a passage. Insert the rectal tube within the rectum, then allow fluid to flow in, and as the rectum becomes distended the folds no longer impede and the tube then may be inserted further. The rectum is also richly supplied with blood vessels, the blood returning by the hemorrhoidal veins which have no valves. Chronic constipation, with the accumulation of feces, causes pressure on these veins, which is increased by straining at stool, and may cause congestion forming hemorrhoids or piles. These may be internal or external, may become inflamed and bleed easily. There are many nerves at the anus so that it is always very sensitive. Hemorrhoids are very painful and when these are present, unusual care must be taken when inserting a rectal tube. The patient's mental reaction to a treatment of this kind, espe- cially if given for the first time, must be remembered, and her feelings of natural reserve and sensitiveness respected. Even though the patient should be unfortunate enough to lack these 114 THE PRINCIPLES AND PRACTICE OF NURSING natural feelings, the nurse owes it to herself and the standards she upholds to see that the patient and the procedure are screened from view, and that only the necessary exposure is made. This applies equally to public and private patients. The nature and benefits of the treatment should be explained. Method of Giving an Enema.—The articles required for the treatment (depending upon the technique used) will be a bath blanket, a basin, a funnel with a rectal tube attached, a pitcher with the solution, vaseline, a rubber and sheet to protect the bed, a bedpan, a basin of water, paper and cotton pledgets to cleanse and dry the patient and a paper bag. Sometimes when a large amount of solution is to be injected, instead of pouring it from a pitcher into a funnel, it is allowed to run from a douche can through a long piece of rubber tubing (about 3 feet long) attached to the can, provided with a clamp, and connected by a glass connecting tip to a rectal tube. The can hangs from an irrigating pole. The bed should be protected and the draping and bedclothes arranged so as to avoid exposure of the patient and possible con- tamination or lingering odors. Position of the Patient.—The patient should be drawn to the side of the bed, turned on her left side (when possible), so that the fluid, by gravity, will flow into the sigmoid and descending colon. The knees should be flexed, the right slightly more than the left to relax the abdominal muscles. The position is also one of ease and comfort. In some post-operative cases and where the sphincters are relaxed or the perineum or sphincters torn it may be necessary to give the treatment with the patient in the dorsal, recumbent position. When the sphincters are relaxed or torn so that it is impossible for the patient to retain the solution even for a few minutes it will be necessary to first place the bedpan under the patient. This is a most uncomfortable and undesirable position and should never be used in any other cases. Before inserting the tube it should be oiled with vaseline and the water should be allowed to run through to warm the tubing and expel the air. Air introduced may cause colic. Insert the rectal tube just within the anus, allow fluid to run in, then insert it for about six inches. If it is desired to have the patient retain the solution in order to soften the feces, or if it is necessary to inject a large amount, give it very slowly and evenly so as not to excite the bowel to contraction. When given quickly the sud- den distention and irritation cause peristalsis and immediate evacuation. If given too cold or too hot, the same results. While the fluid is flowing in, see that the funnel or irrigating can does not become empty, thus allowing the entrance of air. If the patient complains of pain, pinch the tube and stop the flow for a minute. If the fluid does not run in freely, moving the tube slightly sometimes helps, or it may have to be removed and cleansed, if clogged. After the desired amount has been given, if the enema is not THE ELIMINATION OF BODY WASTES 115 to be retained, pinch the tube and remove it gently. Then turn the patient on her back, at the same time place the bedpan under her being sure that it is straight and in the center to avoid an overflow. The bedpan should be warm. Arrange the drap- ing so as to protect the bed from fluid and fecal material apt to be scattered by the forcible expulsion of flatus. After the enema is expelled, remove and cover the bedpan; turn the patient on her side, cleanse and dry the parts thoroughly. Remove the rub- ber, etc., and rearrange the clothing. Clear away the articles, cleanse, and put in their proper places. This treatment may be very exhausting for weak patients. They should be closely watched and guarded from all unneces- sary exertion or discomfort. Chart the results—whether the return was satisfactory, whether it was fluid or contained small, hard masses, the amount of flatus and the presence of any other abnormality. If the patient cannot expel the enema, report it to the head- nurse, reinsert the rectal tube, placing the end in a bedpan. Retention of a soapsuds enema is apt to occur when the patient has been deprived of fluid or the body has lost much fluid. The solution injected is then absorbed to relieve thirst and supply fluid of which the tissues are in need. Measures Used to Aid Retention.—When it is desired that an enema be retained it is necessary to avoid all stimuli, either mental or physical, which might excite peristalsis in the intes- tines. First reassure the patient, see that he is mentally at ease and avoid during the treatment anything which might cause excitement, anxiety or distress. Avoid unnecessary exposure, pain or discomfort and anxiety as to the danger of expelling the enema and soiling the bed. The patient should be comfortable, all his wants attended to so that he may be quiet and undisturbed after the treatment. The amount of solution used should be small, it should be injected very slowly and gently through a rubber catheter, well lubricated and inserted very gently. Spe- cial care should be taken after operations. The catheter should not be lubricated with glycerin as it excites peristalsis. The tube should be inserted as high as possible, that is about 6 to 8 inches. If the temperature of the solution is near that of the rectum there is less danger of expulsion. After the injection is made remove the tube very gently or it may be clamped off and allowed to remain inserted to prevent expulsion. Pressure to the anus with a folded towel may be applied for a few moments until excitement of the intestines caused by the treatment has sub- sided. The Care of Rectal Tubes.—Rectal tubes must be thoroughly cleansed both inside and out, first with cold water, then with warm soapy water. The inside is cleansed by allowing the water to run through them from the hole in the tip to the outlet. They are then boiled for three minutes in water containing a little salt to prevent softening of the rubber. Then allow to drain, 116 THE PRINCIPLES AND PRACTICE OF NURSING dry and put away in the proper place. After an oil enema the catheter or rectal tube should be cleansed immediately as oil destroys rubber. Hard rubber rectal tips are occasionally used. Hard rubber should never be sterilized by boiling as it is ruined by the heat. It is sterilized by immersion in a disinfectant solution such as carbolic, cresol, or formalin. This applies to hard rubber whether used in rectal tips, douche tips, atomizers or other articles. Rectal injections, even the simple cleansing enema, should only be used when ordered by a doctor. Their prolonged use develops into a custom, paralyzes the muscles and makes artificial means of evacuation a necessity. THE STOOLS OF A NORMAL INFANT When on duty in the Infants' Ward, a probationer may be required to change the soiled diapers of infants not acutely ill. When doing so it is important that she should note the character and number of stools passed during the day. The Number of Stools.—A normal breast-fed infant should have two or three stools each day during the first week. It is very important for the nurse to watch the number and character of the stools during this period. An absence of bowel movement may be due to some congenital malformation of the anus, rectum, or colon, which should have the immediate attention of a surgeon. After the first month there are usually two stools each day, but there should be at least one. A normal artificially fed infant should have at least one stool a day. The Character of the Stool.—This is of even greater im- portance than the number. The stool of a breast-fed infant is orange-yellow in color, soft, smooth, mealy or stringy in con- sistency, having a pungent odor and acid reaction. The stool of an artificially fed infant changes in appearance with the food given. For instance, when nothing but milk is given, the stool is lemon yellow in color; when malt, starch or beef-juice is given it is brown in color. The consistency is salve-like. The character of the stool is an important indication of whether the infant is getting the proper feeding or not. For instance, the presence of large, hard curds in the stools indicates usually too much protein in the diet. The stools may be otherwise normal or they may be frequent in number, large and watery in char- acter, alkaline in reaction, and either green or brown in color. The presence of soft curds in stools which are large, dry, shiny and gray indicates too much fat in the diet. Stools which are watery and green in color, highly acid and irritating to the tissues indicate too much sugar in the diet. If there is any abnormality in the color, odor or consistency THE ELIMINATION OF BODY WASTES 117 of the stool, the nurse should save it for the inspection of the headnurse, who will show it to the doctor if advisable. The number and character of the stools are recorded on the chart. The Method of Changing the Infant's Diaper.—Infants should never be left with soiled or wet diapers. Damp clothing about an infant always predisposes to chilling and cold. In changing an infant's diaper some of the important things to remember are as follows: The room should be warm. The nurse should be properly pro- tected. After removing the soiled diaper the buttocks and geni- tals are carefully cleansed, dried, and powdered. Olive oil is used for cleansing because it is soothing and helps to keep the skin in good condition. Warm water and soap are used for cleansing only when absolutely necessary because frequent wash- ing is apt to make the parts tender. If the skin is irritated and red, the nurse should report this to the headnurse. A soothing ointment (such as a mixture of Lassar's paste and olive oil) may be applied. If the buttocks are very sore, the treatment fre- quently used is to expose the buttocks to heat ravs from an elec- tric light suspended from a cradle in the bed. In putting on the clean diaper the important things to remem- ber are to select a diaper suitable in size to the size of the infant, to fold it properly so that it may be securely fastened in place and serve the purpose for which it is applied without caus- ing pressure or interfering with the natural position, freedom of movement, and growth of the infant's legs. The ends of the diaper should be fastened and tucked in neatly and smoothly. The folds should be flat and smooth, never bulky. Safety pins only should be used to fasten the diaper. A sufficient number should be used to securely fasten it and prevent the escape of feces. The pins must be in good condition and secured so that they cannot come unfastened and injure the child. Changing a diaper is a procedure which requires considerable skill. Babies are rather difficult to handle because they are so small, weak and helpless or very restless, and the change must be made quickly and without unnecessary exposure. As in all other procedures skill will only come with practice, patience, thought and care. Formation of Regular Habits.—One of the nurse's most im- portant duties is to train an infant in the'habit of passing the stool and voiding urine at regular intervals and at a definite time. As explained previously, this regularity is of the utmost importance in the prevention of constipation, and all the ills which follow. Training cannot begin too early. A habit will be formed which may last throughout life and be of the greatest benefit. If the training is begun early the habit of regularity in defecation may be formed by the end of the second or third month and regularity of voiding urine at the end of the first year. 118 THE PRINCIPLES AND PRACTICE OF NURSING Dr. Holt gives the following directions: "A small chamber, about the size of a pint bowl, is placed between the nurse's knees, and upon this the infant is held, its back being against the nurse's chest and its body firmly supported. This should be done twice a day, after the morning and afternoon feedings, and always at the same hour. At first there may be necessary some local irritation, like that produced by tickling the anus or intro- ducing just inside the rectum a small cone of oiled paper or a piece of soap, as a suggestion of the purpose for which the baby is placed upon the chamber; but in a surprisingly short time the position is all that is required. With most infants, after a few weeks the bowels will move as soon as the infant is placed on the chamber." Method of Giving an Enema to an Infant or Young Child.— In giving a cleansing enema to an infant, provision must be made for the immediate return of the solution as the infant will not retain it. The solution used may be a mild soapsuds or normal salt solution. A catheter is used instead of a rectal tube and an irrigating can, rubber tubing and connecting tip are usually used instead of the funnel. The irrigating can should not be more than one foot above the child. To give the irrigation the nurse protects herself with a rubber apron which is allowed to hang into a receptacle on the floor. The infant lies on her lap, either on its back or side, with its legs flexed on the abdomen and its buttocks resting at the edge of the nurse's knees. The child may be held securely and firmly in this position. Restraint should not be used if possible to avoid it. Try to calm fear, nervousness or struggling, if present, before beginning the treatment as they interfere with attaining the results desired. Considerable flatus may be expelled so that it is wise to arrange the draping so as to avoid soiling of sur- rounding articles. This treatment must be given with extreme care and is usually assigned only to an experienced nurse. All the precautions to be observed in giving treatments to adults are of even greater importance when the treatment is given to infants or children. CHAPTER XII THE ELIMINATION OF BODY WASTES (Continued) THE ELIMINATION OF WASTE PRODUCTS BY THE KIDNEYS A nurse should note, particularly, the amount of urine voided in twenty-four hours, the amount at each voiding, whether void- ings are frequent or not, whether any pain, discomfort or diffi- culty is felt in passage, and the color, odor, and transparency of the urine. The Amount.—The normal amount of urine voided by an adult varies from 1000 to 1500 c.c; by a child (two to fourteen years) from 450 to 1500 c.c. A normal adult voids from 8 to 10 ounces every 4 to 8 hours. Patients should be given the bedpan or urinal at regular hours, usually before meals and before bed- time. The amount of urine voided may be greatly increased tem- porarily by drinking a large amount of fluids, by nervousness and excitement, by exercise, by cold baths and by the action of diuretics. In winter urine is usually voided more freely because less water and waste products are eliminated by perspiration. The amount is usually increased in hysteria, during a crisis in an acute disease, in chronic nephritis, in diabetes mellitus and in diabetes insipidus. In an acute disease the temperature is high, the skin is usually dry, and the kidneys do not eliminate freely; during the crisis the temperature falls; all the avenues by which the body loses heat are opened so that the patient usually per- spires freely and voids a large amount of urine. In chronic nephritis the diseased kidney has difficulty in eliminating the solid waste products so it eliminates a small amount of solids and to dilute and make them less irritating, it at the same time eliminates a very large amount of water; the urine will be pale and of a low specific gravity. In diabetes mellitus the tissues are unable to burn sugar so it accumulates in the tissues and in the blood. The patient is very thirsty and drinks quan- tities of water because the body must have a large amount of water to dissolve or dilute the sugar and eliminate it through the kidneys. The urine will be pale in color, but the specific gravity will be high because although there is a large amount of water there is also a large amount of solids due to the sugar eliminated in the urine. 119 120 THE PRINCIPLES AND PRACTICE OF NURSING The voiding of a large amount of urine is called polyuria. The amount of urine voided may be greatly decreased by drinking small amounts of fluids, by the loss of body fluids by other avenues—by free perspiration, as in the summer, by vomit- ing, diarrhea, a severe hemorrhage, and by the action of drugs, such as opium, which checks the secretion of urine. The secre- tion may also be checked in poisoning from such drugs as bichlo- ride of mercury, which so irritates the kidney cells as the body tries to eliminate it as to completely or partially cause loss of function. The toxins formed in all the acute diseases, such as pneumonia, diphtheria, and scarlet fever, have the same injuri- ous effect on the kidneys. In acute diseases the voiding of a large amount of urine is usually a favorable symptom. In acute nephritis and in heart diseases which cause poor circulation in the kidneys, the amount of urine voided may be very small. When the amount of urine voided is scanty, the condition is called oliguria. When there is a total absence or a marked defi- ciency the condition is called anuria. In diseases marked by either an increase or decrease in the amount of urine voided, it must be very carefully measured and accurately recorded on the chart. Anuria or failure to void urine may be due either to retention or to suppression of urine. It is very important to know to which anuria is due for the effect on the body and the treatment required differ greatly. Retention of Urine.—Retention means that the urine secreted by the kidneys is retained in the bladder. Retention with overflow sometimes occurs, that is, some urine is voided, but the bladder is not emptied and the patient com- plains of a feeling of fulness and discomfort. The distended bladder may sometimes be felt. The symptoms of retention are (1) failure to void; (2) a feel- ing of fulness and discomfort, sometimes amounting to severe pain; (3) a distended bladder. Any of the above symptoms should be noted by the nurse and immediately reported. When the bladder contains urine but the act of voiding does not occur, means must be taken to cause its expulsion or to remove it by artificial means. If simple nurs- ing measures fail to relieve the retention, catheterization must be resorted to. This treatment is accompanied by considerable risk to the patient and should only be carried out by a nurse with experience, knowledge, and skill, so will be discussed in a later chapter. Before catheterizing a patient or even reporting that she is unable to void, every nursing measure should be tried to cause the bladder to empty itself in a normal way: The measure of a good nurse lies in her ability to use her science and art to restore her patient to normal by nursing measures which render drugs and treatments (which may possibly do harm) unnecessary. Nursing Measures to Cause the Patient to Void.—To use nurs- THE ELIMINATION OF BODY WASTES 121 ing measures to restore the patient (or the functions of the blad- der) to normal, intelligently, we must recall what this normal function consists in and find out what the interference may be. Normally the urine passes drop by drop from the ureters into the bladder, where it is stored until about eight to ten ounces have collected. Under normal conditions this causes a desire to expel it. The nerve endings in the lining of the bladder are irritated or stimulated by the pressure of the accumulated urine and this message of pressure, irritation, or of something hurting or injuring, is carried along nerve fibers to the center in the sacral region of the spinal cord which controls the bladder. This center sends a message back along other nerve fibers to nerve endings in the muscular wall of the bladder which causes them to contract and expel or force out the irritating substance. This is called a reflex act and the act is called micturition or voiding. It is only partially under our control for the cells in the spinal cord communicate with and to a certain extent may be controlled or greatly influenced by certain cells or centers in the brain. So failure to void may be due to any one of these factors: (1) The nerve endings in the bladder may be dull or insensitive as from indolence and failure to respond. (2) The nerve centers in the cord may be injured, depressed or stunned so that they fail to recognize, receive or send out any messages. This may be due to drugs such as alcohol, morphine or ether in a general anesthetic or it may be due to shock following an injury or operations on the pelvic organs with more or less exposure and injury to the bladder; or it may be due to the mental condition— depression, worry and painful emotions and it may also be due to physical pain. (3) Nervousness may cause a spasmodic contrac- tion of the urethra making it impossible for the bladder to expel the urine. (4) The muscles of the bladder may have lost their tone from old age, anemia, or from a greatly distended bladder when, for instance, circumstances have prevented the bladder from relieving itself for a long time. The muscles may also be cramped or partially paralyzed by exposure to cold as during a prolonged operation. The following nursing measures may help the patient to void: (1) Try to relieve any mental distress present—cheer and reas- sure the patient, remove the cause of nervousness and, if pos- sible, find out what is the cause of worry if present. Give the patient something else to think about. (2 > Remove any physical pain or discomfort. (3) See that the patient is not kept waiting so long for the bedpan that the desire to void is lost. See that the bedpan i-s given warm and at regular intervals to encourage micturition—this reflex act, or stimulus and response. (4) Stimulate the reflex act by suggestion which is a powerful mental stimulus—by the sound of running water—a tap left running nearby or water poured from one pitcher to another or by pour- ing hot water over the vulva into a warm bedpan placed under the patient. Sometimes the suggestion that catheterization will 122 THE PRINCIPLES AND PRACTICE OF NURSING be necessary acts as a powerful stimulus. (5) Stimulate the nerve endings in the bladder by drinking freely large amounts of water so increasing the elimination and pressure in the bladder. (6) Stimulate the muscles to contract by the application of heat—a warm bedpan, pouring hot water over the vulva, applying hot fomentations or a hot water bag over the lower abdomen (a doctor's order will be necessary), and by keeping the feet and body warm. (7) Stimulate the circulation and contraction of the muscles by gentle massage over the lower abdomen if per- mitted. (8) Failure to void is often due to the patient's un- natural position. If allowed to sit up she may have no difficulty. Frequently even after operations the surgeon will prefer to allow the patient to sit up on the bedpan (securely supported by the nurse) rather than run the risk of catheterization. In some cases I have known the surgeon even to allow the patient to sit up with her feet resting on a chair at the side of the bed. Suppression of Urine.—Suppression means that the kidneys are no longer able to do their work. This is a very grave con- dition. The waste products circulating in the blood, which nor- mally the body eliminated through the kidneys, find this outlet or means of escape cut off, so that they are suppressed, held back, and denied a passage. They have travelled a long way, coming from every cell in the body, only to find, as it were, when they reach the kidneys, the doors closed, and, let us suppose, a sign which reads "Failed" or "Shop closed for repairs." The body must find another means of getting rid of them. Some waste will be eliminated by the bowels and some by the skin, but the skin and bowels combined cannot do the work of the kidneys entirely, so that these waste products accumulate in the body and soon give rise to very serious symptoms of distress and disease. The symptoms of retention of urine are largely local, that is, confined to the region of the bladder, but with sup- pression of urine the symptoms are general, for there is probably not a cell in the body which is not injured and hampered in its work. The symptoms of suppression are dizziness, nausea, headache, dimness of vision or seeing bright spots before the eyes, puffiness under the eyes, or a general swelling. A very small amount of urine and in severe cases no urine will be voided. In suppres- sion when a catheter is inserted into the bladder no urine is obtained, because there is none there, whereas in retention the urine will immediately start to flow. The treatment for suppression is (1) to encourage the elimina- tion of waste products through the skin and bowels by hot packs and colon irrigations; (2) to rest and relieve the kidneys by care- ful regulation of the diet; (3) to give "forced fluids," so as to dilute the waste products and aid in their elimination; (4) to apply local relief to the region of the kidneys by "cupping" and "stupes"; (5) to stimulate the kidneys by diuretics and colon irrigations. THE ELIMINATION OF BODY WASTES 123 Report immediately any failure on the part of the patient to void the normal amount of urine. The Transparency of Urine.—Normal urine is always clear and transparent; on standing nothing but a delicate floating cloud is seen in the center. Normal urine is acid in reaction and always contains waste products in the form of phosphates which are held in solution by the acid medium. Under certain conditions (due to carbohy- drate diet, etc.) the urine may become alkaline so that the phos- phates are no longer held in solution, but are precipitated out, making the urine very cloudy and forming a sediment on stand- ing. Normal urine on standing becomes alkaline and cloudy because normal waste products in it (the urea) are decomposed by bacteria into its original constituents, setting free ammonia which is highly alkaline. This will cause the phosphates to be precipitated. People are sometimes needlessly alarmed, think- ing they have "kidney trouble" when this urine, on standing, becomes cloudy. Adding a little acid to the urine will determine whether the "cloudiness" is due to phosphates (which are nor- mal in urine) or not; if to phosphates, the cloud will disappear. People are also sometimes needlessly alarmed by a thick, turbid urine and a brick red sediment on standing. This sedi- ment consists of urates and uric acid crystals, normal waste products in the urine. Urine when voided is warm and this heat keeps the urates, etc., in solution, so that the urine looks quite clear. When cooled, particularly if concentrated, they are no longer held in solution. To test the urine heat it; if the cloud or sediment is due to urates it will disappear. When a cloud or sediment however can neither be removed by adding acid or by heating, but rather becomes coarse on heating, it is always due to abnormal substances—albumin, pus, blood, epithelial cells or casts—which indicate disease of some part of the urinary tract. The presence of albumin, pus, blood or epithelial cells may indicate disease of the bladder (cystitis), or of the kidneys, but the presence of casts always indicates disease of the kidneys. The Color of Urine.—The color of urine depends upon the amount and kind of pigment, the concentration of the urine, the amount and kind of solids, decomposition of the solids in it, the presence of abnormal constituents, and the action of various drugs. The pigments may be increased or decreased—increased uro- bilin (the chief coloring matter in urine, derived from bile, which in turn derives its coloring from hemoglobin from the wornout and decomposed red blood cells) is present in all febrile condi- tions and makes the urine dark; concentrated urine is dark while dilute urine is pale; very dark, smoky urine may be due to the presence of blood or poisoning from carbolic acid; increased urates give a brick-red color; bile pigments give a greenish- yellow color; decomposition of pigments may give a pinkish 124 THE PRINCIPLES AND PRACTICE OF NURSING color; the presence of pus or chyle gives a whitish or milky ap- pearance—chyle is present in filariasis; the action of drugs—■ such as rhubarb and senna give a bright orange color; methylene blue gives a blue-green color; iodoform, a dark greenish color. The color of urine is not of any great importance in diagnosis. The odor of urine is said to be characteristic, that is, it is like nothing else—the odor of urine about a patient is unmis- takable. It is due to various volatile, aromatic substances in it. As previously stated, when urine is allowed to stand its urea decomposes, liberating ammonia; decomposed urine therefore has the odor of ammonia. Where freshly voided urine has this odor it shows that decomposition has already taken place in the bladder; this indicates cystitis. In diabetes the urine may have a sweetish odor due to the presence of acetone. The odor of ammonia or of acetone should, therefore, always be reported, as they indicate disease. Various drugs and also various arti- cles in the diet also alter the odor of urine. THE COLLECTION OF SPECIMENS OF URINE The way in which the kidneys are working and the waste products contained in the urine have such an important bearing on the patient's condition, the diagnosis and treatment, that a "routine" specimen of urine is sent to the laboratory for exam- ination, that is, it is an understood rule that on the admission (or on the following morning) of each patient, a specimen of urine will be sent for examination. A "Routine" Specimen.—A "routine" specimen is the urine passed in one voiding. The whole amount voided may be sent for examination, but only four ounces are necessary for the tests in a routine examination. Food and exercise cause a temporary change in the urine, therefore the best time to collect a routine specimen is before breakfast. It will be examined for: 1. Its Reaction, that is, whether it is acid or alkaline. Nor- mal urine is acid because, on a mixed or average diet, more foods are eaten which yield acid waste products as a result of their metabolism than foods which yield alkaline. The reaction may vary somewhat, therefore, with the diet. II. The Specific Gravity, which depends upon the amount of solids in the urine in proportion to the amount of water. It is based upon water as a standard—one liter of water at a certain temperature weighs 1000 grams. Urine is heavier than water, because of the solids contained in it. The specific gravity of normal urine varies from 1.012 to 1.024 far an adult, and for a child from 1.008 to 1.020. In disease it may be as low as 1.002 (showing that the kidneys are eliminating a smaller amount of solid waste in proportion to the amount of water), or it may be as high as 1.060, showing the presence of a large amount of solids. THE ELIMINATION OF BODY WASTES 125 III. The Presence of Epithelial Cells and Leucocytes, or white blood cells. The kidney tubules, which secrete the urine, the ureters and the bladder are lined with epithelial cells. These are being constantly worn out and shed in the urine (just as the cells of the outer skin), so that there will always be a few epi- thelial cells in the urine. Many epithelial cells, however, indi- cate increased destruction of these cells and so indicates disease of the lining of the kidney tubules, the ureters or the bladder. Where there is disease—irritation or inflammation—there will always be an increased number of leucocytes whose duty it is to help, to protect and to repair the damage. IV. The Presence of Albumin.—Albumin is a body protein which circulates in the blood to supply the cells and which forms a necessary constituent of all body cells. Normally, in the urine there is a slight or "faint" trace of albumin, but too small an amount to be detected by the ordinary tests used. The products of inflammation—many epithelial cells, leucocytes or pus—will cause a "marked trace" of albumin in the urine, so that in in- flammation of any part of the urinary tract—kidneys, ureter, or bladder,—albumin will be present in the urine. Some people are said to have a functional disturbance of the kidneys, that is, their urine will contain albumin after a cold bath, excessive exercise, or a high protein diet, without having inflammation of the kidneys. The presence of a "marked trace" of albumin in the urine, however, is generally accepted as an indication of nephritis, which is a very serious disease, important to recognize in its early stages. So generally is this accepted that no life insurance policy is ever granted without testing the urine for albumin. If a "marked trace" of albumin is found the policy is not granted. Albumin in the urine may result from the following condi- tions: 1. Acute nephritis, in which the amount of albumin may be so great that when the urine is heated it forms a jelly—albumin coagulates when heated like the white of egg, which is largely albumin. 2. In febrile conditions, as in scarlet fever and diphtheria, etc. The increased body temperature, the increased destruction of body tissues, the toxins produced by the bacteria all have a very injurious effect upon the kidneys and may themselves produce an acute nephritis. Nephritis is one of the dreaded complica- tions to be guarded against in these diseases. 3. Poisoning by ether, bichloride of mercury, carbolic acid, lead and cantharides, etc. These are all irritating, poisonous and destructive to the body cells, and in whatever way taken into the body, must be eliminated by the kidneys. They not only increase the work of the kidneys by increasing the waste products to be eliminated, but in their passage through the kid- neys into the urine they irritate and destroy the secreting cells. 126 THE PRINCIPLES AND PRACTICE OF NURSING 4. An uncompensated or failing heart. The blood pressure will be low, the circulation in the kidneys will be poor, so that the kidney cells will be very poorly nourished. The life and function of the cells and the normal secretion of urine depend upon the free circulation of blood through the kidneys. 5. In all severe cases of anemia. The poor quality of the blood causes degenerative changes in all the organs of the body, including the kidneys. 6. In pregnancy.—Nurses often do routine examinations in pre-natal cases to detect such signs. V. The Presence of Sugar or Glucose.—Normally there is a very faint trace of sugar in the urine. Eating a large amount of candy may cause temporarily a marked increase of sugar to appear in the urine in a perfectly healthy person. With no such cause, however, the presence of sugar indicates that the patient is suffering from a very serious disease—diabetes. In this dis- ease the body cells are unable to burn the normal amount of sugar supplied them as fuel, and so are unable or have difficulty in producing the necessary heat and energy for the body proc- esses. As the sugar eaten is of no use to the body, and the blood will only carry a certain amount, Nature gets rid of it by elimination, and as glucose readily passes through any mem- brane, it overflows from the blood into the urine. In severe cases of diabetes the amount of sugar in the urine may rise as high as 10 per cent. The presence of sugar in the urine does not indicate disease of the kidneys. Students frequently have the impression, that be- cause the presence of sugar in the urine is abnormal, the kidneys must be diseased. This is not the case, for, as stated above, glucose will readily pass through any membrane, either within or without the body. However, as sugar is irritating to the tissues, the constant passage of sugar through the kidneys into the urine may set up an inflammation so that nephritis may com- plicate diabetes. A "Pre-operative" Specimen.—A "pre-operative" specimen of urine is one collected and examined in the morning previous to the operation, if the patient is to be given ether or chloroform as a general anesthesia. The surgeon will not operate until a report of the examination assures him that the kidneys are nor- mal and also that the patient is not suffering from diabetes. The urine is therefore particularly examined for albumin (which indicates nephritis) and sugar (which indicates diabetes). As previously stated, ether and chloroform are very irritating to the kidney cells, so that if the patient already has even a mild nephritis any additional irritation may set up an acute nephritis from which he may not recover. In diabetes there is an increased amount of sugar in the blood. This increased amount of sugar in the blood so interferes with the metabolism of the cells that the wound may not heal. A "Post-operative" Specimen.—A "post-operative" specimen THE ELIMINATION OF BODY WASTES 127 is sent for examination to find out the effect of the anesthetic on the kidneys. A faint trace of albumin is almost always pres- ent, showing slight irritation of the kidney cells due to the ether. The Method of Sending Urine Specimens to the Laboratory. —The above specimens, specimens of one voiding or at least four or five ounces, should be sent to the laboratory in a clean bottle, securely corked with non-absorbent cotton, and to which a tag is attached on which is clearly marked the date and time collected, the name of the ward, the patient's name, and for what the urine is to be examined. The bedpan or other recep- tacle used must be scrupulously clean. When a routine specimen of urine is required from a patient who is menstruating, the vagina should be plugged with cotton to prevent the blood from contaminating the urine. Otherwise the result of the examination would be most misleading. It is not necessary to catheterize the patient. A Twenty-four-Hour Specimen of Urine.—Its Value and Im- portance.—If the routine specimen of urine on examination shows the presence of abnormal constituents or if the disease from which the patient is suffering makes a more thorough examina- tion desirable, all the urine secreted by the kidneys during a period of twenty-four hours is measured (and the amount charted), saved, and sent to the laboratory for examination. All the urine voided while the patient is in the hospital or as long as desired may be saved in this way for examination. With a specimen of one voiding, it is possible only to make a qualitative analysis, that is, to find out what constituents or wastes are present, but not a quantitative analysis, that is, to find out how much of each waste product is present. With a twenty-four- hour specimen—the total amount secreted by the kidneys—it is possible to estimate not only what wastes the kidneys are eliminating, but the quantity of each and so to form an accurate idea of not only how the kidneys are working, but of how foods are being utilized in the body, and also of other processes of metabolism. Again as the urine is altered by diet and exercise, the only way to obtain accurate results is to examine the full amount voided during the day. As the diagnosis, the diet, and general treatment may to a large extent be based on the findings in this examination, and also as the tests are very tedious, and involve a great deal of money and the time of chemical experts in the laboratory, it is extremely important that no mistakes should occur in collecting, saving or sending for examination, and that all the urine secreted by the kidneys should be examined. Otherwise the findings, the results of hours of work will not only be useless, but if used would be very misleading and lead to a faulty diagnosis and treatment. Errors in Collecting to be Avoided:— 1. See that a large bottle is properly tagged with the date, the hours at which obtained, the name of the ward, the patient's 128 THE PRINCIPLES AND PRACTICE OF NURSING name, the nature of the specimen and for what it is to be exam- ined. Errors are often avoided if information on these tags is printed, not written. 2. See that by no possible error could specimens from differ- ent patients become mixed by emptying in the wrong bottle, etc. Keep your mind on your work and read the tag carefully. 3. See that the receptacle used is scrupulously clean. 4. See that the specimen bottle is scrupulously clean, prop- erly corked with non-absorbent cotton, properly tagged, and kept in a cool place. 5. See that no urine is lost by spilling in the bed, or by other accident. Avoid having the patient void urine at the same time as passing a stool. Try to have them void at regular intervals and before passing a stool. Use two bedpans if necessary. If the patient is likely to have involuntary micturitions give the bedpan at intervals frequent enough to avoid this loss. Never empty the bedpan without finding out whether the urine is to be saved. 6. See that the amount sent for examination is the urine secreted by the kidneys during that period, and not that merely voided or expelled from the bladder. The examination is to find out how the kidneys are working, and not how the bladder is working. For instance, a twenty-four-hour specimen is collected from 6 A. M. of one morning (or at whatever hour designated by the doctor or rules of the ward) to 6 A. M., that is, exactly the same hour on the following morning. Now the urine voided at 6 A. M. of the first morning has been secreted by the kidneys and collected in the bladder during several previous hours—we do not know how many—and so must not be included in the twenty-four-hour specimen begun at that hour. The patient should void and empty the bladder at 6 A. M. (if that is the time for beginning), and this urine should be thrown away. If the bladder is now empty we know that all the urine voided up to and including 6 A. M. of the following morning must have been secreted by the kidneys. For the same reason, to make our collection complete, we must see that the patient voids, and that the bladder is emptied at 6 A. M. of the following morning, because the urine contained in the bladder at that time has been secreted by the kidneys during the period that they are under examination. Otherwise our results would be most inaccurate. 7. If by any unavoidable accident, urine should be lost, make a note of this on the tag, and also on the patient's chart. A twenty-four-hour specimen may be examined for: I. The total normal constituents or waste products of meta- bolism. The function of the kidneys in the healthy body is to eliminate (and therefore these are the normal constituents of urine) — (a) excess water; (b) the ashes or wastes of protein metabolism; (c) the inorganic salts not required in the body. II. The total abnormal constituents, the products of incom- plete or faulty metabolism and of disease. THE ELIMINATION OF BODY WASTES 129 The Ashes or Wastes of Protein Metabolism.—These include the ashes resulting from the metabolism of the excess protein food absorbed from the diet (we all eat more protein than the tissues require) and also from the breaking down of the body tissues. These wastes of protein metabolism are chiefly in the form of urea, uric acid, and creatinin. All proteins and protein wastes contain the elements nitrogen, carbon, hydrogen, and oxygen, nitrogen being the essential ele- ment which distinguishes it from the other foods, carbohydrates and fats. Nitrogen forms 16 per cent, of the weight of the protein molecule, so that if the amount of nitrogen in the urine is ascertained the amount of protein from which it was derived can easily be estimated. As the elimination of protein wastes is one of the chief functions of the kidneys, the urine is fre- quently examined for the total nitrogen contained in it. The result not only gives the protein metabolism in the body, but the efficiency of the kidney in getting rid of the wastes. For instance, by subtracting the amount of protein (or nitrogen) eliminated in the urine from the amount of protein (nitrogenous food) given in the diet, and making allowances for the ashes resulting from the breaking down of tissue cells, the amount of protein retained in the body may be estimated: It may have been retained either for the growth and repair of the tissues or because the kidneys failed to eliminate it. The normal daily output of nitrogen in the urine on a regular diet is about 15 grams and as nitrogen equals 16 per cent, of the weight of the protein molecule, this daily output is the waste product resulting from the metabolism of about 94 grams of protein. When the patient is fasting, the daily output of nitrogen is 5.25 grams, which is the product resulting from the breaking down of 33 grams of body protein. This breaking down and loss are constantly going on. A very important lesson is to be gained from the knowledge of this fact which is, that, when a patient is on a fluid diet, in order to prevent this great loss of body protein or life substance, the fluids must be nourishing, for, they must contain protein or nitrogenous food to repair this loss and to build up the tissues. Again, the patient must have rest and sleep and all unnecessary exertion must be avoided in order to conserve and prevent this loss. There will be an increased loss of body protein due to the destruction of body tissues in (1) starvation with marked malnutrition; (2) pernicious anemia in which all the cells of the body are poorly nourished and prac- tically starved; (3) carcinoma and other malignant growths— the tissues are poorly nourished and the destruction of tissues is great, one of the outstanding symptoms of carcinoma being a marked loss in weight; (4) infectious diseases,—because of the patient's loss of weight and the limited diet allowed he is forced to live on his own body tissues to produce the energy necessary to carry on life. Again, the high temperature and the toxins 130 THE PRINCIPLES AND PRACTICE OF NURSING cause a great destruction of body tissues. Patients usually be- come very emaciated with infectious diseases. There will be a decrease in the amount of nitrogen in the urine during convales- cence from disease because the body is retaining the protein to build up the broken down tissues. In all the above conditions the patient requires a diet which is highly nourishing. The urine is frequently examined for the total urea which gives a fairly accurate estimate of the protein metabolism and the efficiency of the kidneys, because 85 to 90 per cent, of all the nitrogen excreted is in the form of urea. Urea is an inert sub- stance, that is, it does not combine readily with other substances, and therefore while a waste product, it is in a form relatively harmless to the body cells. But the intermediary products of which it is composed—ammonium products resulting from the metabolism of protein—are extremely irritating and poisonous and if allowed to accumulate in the body will cause uremic poisoning, an extremely serious and often fatal condition. To prevent this the body, chiefly through the liver and also the body cells, combines and changes these poisonous products into urea which is readily eliminated by the kidneys. It was once sup- posed that the accumulation of urea in the body was the direct cause of uremic poisoning, but urea may be injected into the blood without causing any of the symptoms of uremic poisoning and it will quickly be eliminated in the urine. If the results of these tests show that the metabolism of pro- tein in the body is faulty or that the kidneys are not eliminating the protein ashes as they should, then the patient's diet will be regulated by cutting down the protein and he will be given medi- cations and treatments to prevent the wastes from accumulat- ing in the body. By giving a "low protein diet" the amount of protein ashes to be eliminated and therefore the work of the kidneys will be greatly lessened. They will have as little work as possible to do so that they may have a chance to rest and to turn all their attention to repairing the damage to their cells which prevents them from performing their function properly. In this way only can the diseased kidneys be restored to normal. From the moment of her earliest experience and responsibility with patients a nurse should watch very closely the reports of the urine analysis and the regulations made in the diet, medica- tions, and treatment even though at first they are not entirely clear to her. By degrees they will become clear, and only in this way, and by constant study and observation, can she hope to understand her patient's condition, and intelligently, and with safety to the patient, care for him. The Inorganic Salts.—The chlorides (obtained from the food and eliminated in the urine) form more than all the other salts combined, so that the output of salts, and the efficiency of the kidneys in eliminating them, is tested by finding the "total chlo- rides" eliminated in the urine. The normal daily output of chlorides in the urine on a regular THE ELIMINATION OF BODY WASTES 131 diet is from 10 to 15 grams. If the examination of the urine shows that the kidneys are eliminating less than the normal amount and that therefore the salts are being retained in the body, the patient is usually put on a "salt-free" diet, that is, salt is entirely eliminated—butter, bread, vegetables, etc., are pre- pared free of salt, and no salt is allowed on the tray—in order to prevent the accumulation of salts in the body, to lessen the work of the kidneys, and to lessen the irritation of the salt pass- ing through the diseased kidney. In nephritis the action of salt on the inflamed tissue is very irritating (just as salt on any raw, inflamed surface will smart and sting) and so aggravates the con- dition. The chlorides are more irritating than the other salts. The retention of salts occurs in nephritis with edema, and in heart failure with a sluggish circulation. Retention and Edema.—The tissues must have a certain per- centage of salt (0.5 per cent.). Salts must also be in solution. If the kidneys fail to allow the salts to pass through into the urine they will accumulate in the tissues and as they must be in solution to prevent injury to the cells, and again as fluids always keep up a constant exchange until they are of the same density or osmotic pressure, the tissues will draw water from the blood to dilute the salts. All the tissue spaces between the cells will become engorged with fluid so that the tissues will be "water- logged." This condition is called edema. It begins usually in the loose tissue where there are numerous spaces as in the tissues beneath the eyes or on the back of the hands, which are then said to be "puffy." The edema may become general, that is, all over the body. This condition is called dropsy. Fluid may accumulate in the abdominal cavity; it is then called ascites, or in the pleural sac around the lungs or in the pericardial sac around the heart, and cause the patient great discomfort, diffi- culty in breathing and in the action of the heart, and if the pres- sure is not relieved, may even cause death. In nephritis and heart failure with edema a "salt-free diet" will greatly relieve the condition. By degrees the excess salt (and with it the fluid which was only retained to keep it in solution) will be withdrawn from the tissues and the body cav- ities and eliminated by the kidneys until only the normal amount of salt required by the tissues will be retained. The edema and the patient's discomfort gradually disappear. A "salt-free diet" however is usually very disagreeable to the patient, who nat- urally craves salt and who will sometimes obtain it if possible, in spite of the fact that he knows it will do him harm. To avoid all such errors it is extremely important that each nurse, even the youngest nurse on the ward, should realize the importance of the strict observance of rules in reference to the diet as well as in the collection of specimens. Water.—In many diseases and in some forms of nephritis the patient is encouraged to drink large quantities of water. In some forms of nephritis, however, particularly in nephritis with 132 THE PRINCIPLES AND PRACTICE OF NURSING edema the treatment prescribed by the doctor may be "restricted fluids," so that the patient may be allowed a small amount of water only. A nurse must, therefore, never give even a glass of water to a patient without finding out whether it is permitted or not. The Abnormal Constituents in Urine (the products of faulty metabolism or of disease).—In a twenty-four-hour specimen of urine the total amount of albumin or of sugar may be accurately measured. Other abnormal constituents for which the specimens may be examined are the acetone bodies (acetone, diacetic acid, and (3-oxybutyric acid), indican, ammonia, mucus, pus, blood, urobilin, bilirubin, casts, calculi, iron, iodin, sulphur and bac- teria. These abnormal constituents will be better understood after a wider experience and after having heard and studied the lectures on medical disease, and so will be discussed later. The Collection of a Sterile Specimen of Urine.—When a patient is suffering from a disease of the urinary tract the cause of which may be bacteria or from a disease, such as typhoid, in which the bacteria causing the disease are passed in the urine, the urine is frequently examined in order to detect the presence of bacteria and to find the cause of the disease. A "sterile speci- men" is then necessary, that is, one sterile in the sense that it is not contaminated by bacteria from any external source, so that any bacteria found must have come from the urinary tract. In order to obtain a sterile specimen the patient must be catheter- ized (see chapter on Catheterization). Every aseptic precaution must be taken to avoid contamination. The urine must be re- ceived in a sterile bottle, or other sterile receptacle, and the bottle corked with sterile non-absorbent cotton. The tag at- tached to the bottle must indicate that it is a sterile specimen and state for what the urine is to be examined. THE URINE OF A NORMAL INFANT The Amount of Urine.—In the first month a normal infant voids about 200 to 250 c.c. of urine daily and after the first year 500 c.c. daily. Urination should occur at intervals not longer than every two hours when awake or every four hours when asleep. The Character of the Urine.—The urine is light yellow in color, slightly acid in reaction, having a specific gravity of 1.005, and containing a few leucocytes and epithelial cells. Any abnormality in the amount or character of the urine, such as indicated by an unusual color or staining of the diaper should be noted and reported. A specimen of urine should be sent to the laboratory for examination. Collection of a Urine Specimen from Infants.—In addition to the above conditions, a specimen of urine is usually sent for examination as an aid to diagnosis, where the baby has a con- tinuous temperature from some unknown cause. THE ELIMINATION OF BODY WASTES 133 A specimen of urine may be collected from a boy baby in a test tube fastened in place with adhesive. Various appliances are used for collecting specimens of urine from girl babies. They are not entirely satisfactory. The simplest and most satisfac- tory way of collecting a specimen from a girl baby is to place a small tray under the buttocks. The buttocks only rest on the tray. The gown may be turned back or otherwise arranged so that it will not rest on the tray. The small amount voided (one or two ounces) may easily be collected in this way. The tray should be warm. A layer of gauze if desired may be placed under the buttocks. CHAPTER XIII THE CARDINAL SYMPTOMS TEMPERATURE, PULSE, AND RESPIRATION TEMPERATURE The Importance of Close Observation.—The temperature, pulse, and respirations are so constant and conform with such great regularity to a standard in health that we speak of the normal temperature, pulse, and respirations. The mechanism which governs them is so delicate and so finely adjusted that it responds very quickly to any abnormal condition in the body so that any considerable change or departure from normal is looked upon as a symptom of disease; consequently "taking" the temperature, pulse and respirations is one of the first means used in trying to find out the patient's condition. They are so important and such reliable indications of the condition that one of the first duties of the nurse on the admission of each patient is to take and record the temperature, pulse, and respirations. The first question the doctor will ask the nurse is "What is his temperature?" They are such important signals of distress, showing as they do, a disturbance in the most vital organs and functions of the body, that, whether normal or not, as long as the patient is in the hospital they are taken at least twice during the twenty-four hours. If there is any marked departure from normal they are taken and recorded every four hours. The pulse and respirations in critical conditions will be watched constantly and even though the temperature is not actually taken in order not to disturb the patient, a nurse is on the alert to note any increase shown by the expression of the face, the flushed face, the hot, dry skin, the hands hot and tremulous, the lips dry, parched and tremulous, and the rapid breathing. Again, so important are changes in the temperature, pulse and respirations, so typical of certain diseases and of certain stages in the disease showing its development and decline and the patient's progress, that a special "temperature sheet" is kept on the chart indicating, not only in numerals but graphically by means of dots and lines, the temperature and pulse curves and the relation of one to the other. For instance, in some diseases 134 THE CARDINAL SYMPTOMS 135 the pulse will increase in rate as the temperature increases (as in pneumonia and scarlet fever), while in other diseases, such as typhoid, the temperature may increase without a parallel in- crease in the pulse rate. This "temperature sheet" is usually the first on the chart so that it is the first record the doctor sees on glancing at the chart. From a glance at this alone in some diseases he is able to judge the patient's condition. In some diseases the temperature is so accurate a signal of the patient's general condition that the treat- ment is based upon it. For instance, in typhoid fever, the usual order is to "sponge or tub for temperature 103°." The treat- ment is ordered in this way not because of the temperature, but because the poisons which produced that temperature have like- wise caused very destructive changes in the nervous system and the heart, and it is these rather than the temperature which the treatment is intended to relieve and combat. The tempera- ture is a symptom which may be easily and accurately ascer- tained even by an inexperienced person and it is accompanied by and runs parallel with the other symptoms of injury to the nervous system which are not so definite nor so easily observed and recognized by an inexperienced nurse. These symptoms or signals of distress held out by Nature,— so easily read and unmistakable, so important, interesting and in- structive,—must, therefore, be closely, accurately and conscien- tiously observed and recorded by the nurse. Even when normal day after day and seemingly of little importance or interest in the case, a nurse must never record a temperature, pulse, and respiration carelessly or inaccurately taken or of which she is in doubt—take it over again or have it checked by someone else. Never take the pulse, etc., mechanically or in a routine way, for you are very apt to make mistake's, and changes in the tem- perature, etc., should never be ignored or lightly considered. They indicate that the very citadels of the body are attacked and in distress, for Nature never cries "Wolf! Wolf!" like the boy who tried to frighten and mislead his friends into thinking him in danger. Never be satisfied with any but accurate results; otherwise valuable time is wasted and the results are very misleading and may interfere with the patient's treatment and recovery. It is not expected that a young, inexperienced nurse will under- stand fully the temperature, pulse, and respiration as discussed in the following pages. This can only come with a thorough knowledge of anatomy and physiology and with a gradually widening experience. This experience, however, will be of little value without a knowledge of "what to observe—how to observe ■—what symptoms indicate improvement—what the reverse— which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect" and without a frequent reference to and checking up of experience with the text. 136 THE PRINCIPLES AND PRACTICE OF NURSING THE BODY TEMPERATURE The body temperature, like that of a room or ward, is its de- gree of heat, and is the balance maintained between the heat produced and the heat lost or dissipated. The Production of Heat.—The heat of the body, like that from the burning or combustion of coal in a furnace, is the result of the oxidation or combustion of food, chiefly carbohydrates and fats, but also proteins, in the body. These foods if burned in a furnace would likewise produce heat. As we only eat to live and as this production of heat in the body is so vital, the value of food to the body is reckoned in terms of calories, a calorie being the amount of heat necessary to raise one gram of water one degree Centigrade in temperature. One large calorie (C) is the quantity of heat necessary to raise the temperature of 1000 grams of water one degree. Thus the values of the foods are as follows (Howell): 1 gram protein (heat value) = 4100 calories (4.1 C.) 1 gram carbohydrate (starch) = 4100 calories (4.1 C.) 1 gram fat = 9305 calories (9.3 C.) These figures therefore represent the amount of energy (either in the form of heat or mechanical work) these foods are capable of supplying to the body. In this way the heat or energy value of any given diet may be estimated. Food, however, in the body will not produce heat without oxygen. Just as in a furnace there must be draughts which may be opened or closed in order to regulate the amount of air or oxygen entering according to whether we want the fire to burn up and give more heat or not, so in the body, in order to burn or cause combustion of food with the production of heat, we must have oxygen and a means of supplying it. This, as you know, is provided for by the respiratory apparatus in breathing—oxygen is taken in, carbon dioxide, excess heat, and other waste products, are exhaled. So we must remember that there is a definite rela- tion between the body temperature and the respirations and think of them together. The production of heat in the body is the result of vital work in every organ and cell of the body, but just as in our homes (while we may have fireplaces) instead of having a stove in every room we have a furnace in the cellar where most of the heat is produced and distributed to the whole house by a system of pipes, air or water, and radiators, so it is, so to speak, in the body. WThile every cell produces some heat, some are much more active than others, and so we find most of the heat pro- duced in certain organs—the more active they are, the more food they burn, and the more heat is produced. This heat is also distributed by a system of blood vessels, capillaries and blood, THE CARDINAL SYMPTOMS 137 to other cooler parts of the body, so that while the tempera- ture of both external and internal parts of the body may vary, the body temperature is on the whole uniform. The muscles and the secreting glands are the furnaces of the body where most of the body heat is generated. Everyone knows that, when cold, exercise, or the work of muscles, will pro- duce heat and make the body warm. Shivering, and chattering of the teeth, which are due to the contraction or work of muscles, are two of Nature's methods of producing heat when the body is exposed to cold. A certain amount of glycogen (carbohydrate or animal starch) is stored in the muscles and in the blood, a household and retail supply, so to speak, ready for instant use. Glycogen is also stored in the liver, the wholesale supply ready to be distributed when the muscles have exhausted their own supply and that of the blood. This production of heat by the activity of muscles is a matter of common experience so that we find in hot weather and in warm climates people are languid and avoid both the foods (fats and carbohydrates) which produce heat, and exercise. In cold climates the opposite customs prevail. Again, everyone knows that the ingestion of food, particularly hot foods, will increase the warmth of body temperature. The maximum increase occurs about one and one-half hours after eating. Strong emotions, excitement, worry, nervousness and anger, etc., will also cause an increase in body temperature, and so we have the familiar expression "keep cool" when we really mean not to get excited or angry. These emotions greatly in- crease the activity of the secreting glands, such as the adrenal glands, and so increase heat production. They may also stimu- late the contractions of muscles, such as in trembling with excite- ment or anger, and so increase heat production. Exposure to extremes of temperature in the surroundings—air or water—may also cause an increase in heat production. Exposure to cold, if brief, will stimulate the body to produce more heat in order to protect the body and make up for the heat lost by radiation and conduction from a warmer to a colder body. A high external temperature will also increase heat production because it causes increased activity of all the tissues and upsets the balance of heat regulation by direct action on the heat-regulating center in the brain. A sunstroke, for instance, may increase the body temperature to 107° or 110° F. Conditions which Decrease Heat Production.—Heat produc- tion is much more active in the strong and robust than in the weak or badly nourished, in fasting or starvation, and when the vitality is lowered from any cause, because muscular activity and all the activities from which heat is produced are greatly depressed. They have little heat-producing power, and bear the cold badly. Also during sleep the temperature falls so that it is always lowest in the early morning hours. Anyone who has watched the sick knows that life is at a very low ebb during 138 THE PRINCIPLES AND PRACTICE OF NURSING the early morning hours and that this is a critical time for the patient. Anything which depresses the nervous system, whether it be cold, shock, drugs (such as alcohol or morphine), emotions or mental depression, or unconsciousness, will lessen all the activ- ities of the body and therefore the production of heat. To remember these facts when nursing the sick is extremely important. It is not enough to be able to take the temperature, but we must know, when the temperature is above normal, what nursing measures will prevent a further elevation, and, when it is below normal, what we can do to increase the body heat. For instance, when the thermometer or the appearance of the patient tells us that the temperature is above normal (fever), we must regulate the temperature of the surrounding air, and the amount and kind of bed clothing, etc.; we must prevent all unnecessary exercise or exertion, such as sitting up in bed, reaching for a drink or supporting himself, exertion in the use of the bedpan, in turning or lifting, etc. The patient must have rest and all causes of restlessness and discomfort removed; chilling and shiv- ering must also be prevented; all causes of mental irritation or excitement, such as conversing with visitors, must also be avoided. Any one of these will increase heat production and may cause a relapse. The doctor will probably prescribe rest, fasting (liquid diet, easily digested, of low caloric value), plenty of water to drink, and cold sponging or cold tubs to help control the fever. Again, when the thermometer or the patient's appearance tells us that the temperature is below normal (subnormal), or that he is in a state of collapse or shock, nursing measures must be used to increase heat production. When the natural body proc- esses fail, artificial means must be used by warming the tem- perature of the room, by hot blankets, hot water bags, hot drinks or foods easily assimilated, a hot foot-bath, a hot mustard .bath, and a hot hypodermoclysis, a hot enema, and rubbing the body surface. Oil rubbed over the surface of the skin lessens the elimination of heat; this treatment is frequently used for babies whose vitality or power of producing heat is low. Heat Lost or Dissipated from the Body.—All the heat formed is not stored up in the body—so much heat would burn up our own tissues so that we would die. Therefore there must be a means of elimination. Heat is eliminated in the following ways (Howell): 1. Through the excreta, urine, feces, saliva, which are at the temperature of the body when eliminated. It is estimated that 48 calories are lost daily by the urine and feces. Loss of a large amount of blood, vomiting and diarrhea will lower the body temperature. 2. Through the expired air. This air is warmer than the inspired air, and, moreover, is nearly saturated with water- vapor. The vaporization of water requires heat, which is, of THE CARDINAL SYMPTOMS 139 course, taken from the body supply. Each gram of water re- quires for its vaporization about 0.5 calories. It is estimated that 84 calories are lost daily by the warming of the air, and 182 calories by the vaporization of water from the lungs. 3. By evaporation of the sweat from the skin. The amount lost in this way naturally increases with the amount of sweat secreted. Three hundred and sixty-four calories are lost daily in this way. Profuse perspiration and night sweats will lower the body temperature. 4. By conduction and especially by radiation of heat from the skin. One thousand, seven hundred and ninety-two calories are lost daily in this way. This capacity for such an enormous loss of heat through the skin shows the importance of preserving a healthy condition of the skin through bathing, proper clothing, the avoidance of excess loss of heat through unnecessary exposure at all times, and the value of special treatments (hydrotherapy) applied to the skin. Of course the relative amount of heat lost by the above avenues will vary with the conditions. For instance, in hot weather more heat will be lost by the evaporation of sweat and less by conduction and radiation. Heat Regulation.—The normal body temperature is the bal- ance maintained between the heat produced and the heat lost. It is extremely important that this proper balance be main- tained, for upon this temperature depend the chemical changes which take place in the cells upon which the functions of organs and therefore life itself depends. Anything which interferes with this balance interferes with the functions of the whole body. In warm-blooded animals, this balance is set at a certain standard or level normal for that particular species, just as we have a standard temperature for the ward. The so-called cold- blooded animals, such as the frog or fish, are those whose tem- perature varies with that of the surrounding air or water. The warm-blooded animals are those which maintain a constant tem- perature, summer and winter, practically independent of that of their surroundings. This is accomplished by a heat-regulat- ing mechanism and in man partly by clothing, an artificial means of preventing excess loss of heat through the skin by radiation and conduction. The most important means of controlling the loss of heat from the body is, as we have seen, by controlling that lost through the skin. This is accomplished by centers in the nervous system which control the circulation of blood through the skin and the secretion of sweat. We can understand this loss or dissipation of heat by radiation and conduction better if we refer again to the heating of our homes by a system of pipes, coils or radi- ators. You know that the larger the surface of the radiator, or the more coils, the more quickly a room becomes warm, be- cause a large warm surface is in contact with an equally large 140 THE PRINCIPLES AND PRACTICE OF NURSING cooler surface and so more heat is given off. It is the same in the body. The arteries in the skin subdivide into an enormous number of minute blood vessels, the capillaries, and this multi- plies enormously the surface exposed to the influence of the surrounding cooler air. Through these vessels a very large volume of warm blood from the muscles and glands, etc., flows slowly, giving off some of its heat to the cooler atmosphere before returning to the interior of the body. When the surrounding temperature is very cold the nerve centers (the vasomotor cen- ters which control the size of the blood vessels) cause the blood vessels in the skin to contract so that less blood flows through the surface in contact with the cold and less heat is lost. The sweat centers also check the secretion of sweat so that less heat is lost by evaporation. Again, the effect of the cold on the nerve endings in the skin stimulates the nerve centers which set at work the processes which produce heat—shivering may occur and the appetite is stimulated so that we eat more food. When the surrounding air is warmer the opposite effect takes place; we eat and move about less, the blood vessels in the skin dilate, more blood flows through them, more heat is lost and sweating may be profuse. Increased respiration also increases the loss of heat. It is thought also that in the nervous system there are definite heat- regulating centers which, to meet the needs of the body, can stimulate or inhibit all the activities which result in heat pro- duction or heat elimination. They act, so to speak, like the regulator or thermostat. These centers will struggle against any marked change from the normal temperature until they themselves become exhausted or poisoned by toxins or paralyzed by other means. In infants and young children the heat-regulating mechanism is not so fully developed as in an adult, so that they are very sus- ceptible to the influence of the external temperature, and also to all disturbances likely to cause an elevation of temperature, or fever. The Normal Body Temperature.—The body temperature is measured by means of a thermometer placed in the mouth, axilla, rectum, or vagina. The temperature of the interior of the body is higher than the exterior, the average temperature of the blood being about 102° F., that of the skin being about 90 to 92° F. The temperature of the skin also varies, being higher over a muscle (an active organ) than over bone and higher over an active organ than over one at rest. The temperature of the interior of the body, for instance, the mouth, rectum, and vagina, varies also, according to the blood supply and the extent to which it may be influenced by external conditions. The normal tem- perature in the mouth is 98.6° F., in the axilla slightly lower, in the rectum or vagina about 1° higher than the mouth. The temperature varies during the day and also there are individual peculiarities according to the manner of living and the time THE CARDINAL SYMPTOMS 141 of meals, etc. A person living a confined, sedentary life is apt to have a lower temperature than one living an active, hearty, out-of-door life. The temperature is lowest between 2 and 6 A. M. (the critical hours when the patient will probably need blankets, hot-water bags, hot drinks, etc.), rising gradually dur- ing the day (due to food and exercise), reaching the maximum between 5 and 7 P. M., and again falling during the night. The difference between the early morning and the late afternoon or evening temperature may be a fraction or one degree more. It should be measured therefore for each patient at the same hours each day for accurate comparison. The temperature also varies slightly with age, that of an infant or child being usually 1° higher than that of an adult because the heat-regulating appar- atus is not so efficient. After thirty the temperature is said to fall about 1° below the average, while in very advanced age it rises 1° higher than the average. "In the matter of body tem- perature as in so many other characteristics, aged people show a tendency to revert to infantile conditions." The temperature is also somewhat affected by the temperament, excitable people, for instance, being apt to have a higher temperature. Departure from the Normal Temperature.—Slight varia- tions from 98.6° F. are not usually considered abnormal—varia- tions within the limits of from 97° to 99° are usually not sig- nificant. Apart from the deviations indicated above, compatible with health, any departure from the normal temperature indicates that there is something wrong in the body. The elevation of temperature, however, is not always an index of the serious- ness of the disease, for it may be higher in the shorter, less serious or fatal infections than in the most fatal. For instance, the temperature in tonsillitis is frequently higher than in diph- theria, and in some fatal infections there may be no elevation at all. A prolonged high temperature is always very serious. Recovery seldom occurs at a temperature above 107° F. The following classification is commonly used to describe the various degrees of temperature: Hyperpyrexia.............. 105° F and over High fever................. 103° to 105° F. Moderate fever.............101° to 103° F. Low fever................. 100° to 101° F. Subfebrile.................. 99° to 100° F. Normal................... 98.6° F. Subnormal................. 97° to 98.6° F. Collapse................... 95° to 97° F. Algid collapse.............. below 95° F. The extremes of these temperatures, if maintained, are fatal to life. Even a slight elevation of temperature—99° to 99.6° F. —occurring persistently every afternoon or evening, may be, and frequently is an early symptom of such a serious disease as tuberculosis. 142 THE PRINCIPLES AND PRACTICE OF NURSING Temperatures Above Normal—Fever.—Fever is due to a disturbance of the heat-regulating centers. Heat-production is increased out of proportion to heat-elimination, which may even be diminished. The dry, cold, pale skin present in some fevers shows that heat is not being lost by radiation, conduction, or evaporation. Fever may be due to a variety of conditions and the treat- ment will depend somewhat upon the cause. In sunstroke, in which the temperature may rise to 109 or 112° F., the cause is the exposure to the extreme external heat which increases the temperature of the blood and renders the heat-regulating centers powerless. In that case or in any case where the temperature remains high for a prolonged period, every available means are taken to cause a reduction because the extreme body heat will cause such increased chemical changes, combustion and destruc- tion of the body tissues themselves that death will soon result— even a furnace or an iron stove will finally wear out and be destroyed by continued extreme heat. The temperature in sun- stroke seems to be an unmitigated evil which must be combated. Nervous impressions, hysteria,- and prolonged extreme pain may also cause fever. More common causes are the acute infec- tious diseases, acute local inflammation, such as appendicitis, peritonitis, and infected wounds, toxemia, septicemia, uremia, and ptomain poisoning. In the above conditions, in which the body is being poisoned by the toxins absorbed from bacteria or from decomposing substances, the fever is not an unmitigated evil but a protective, defensive reaction on the part of the body by which it struggles to make the body inhospitable to the bac- teria, so to destroy them and combat their toxins. The way in which the fever is produced is not entirely understood. Some think that the toxins depress the centers which cause heat-elimi- nation. Some think that possibly the heat-regulating centers set the standard or normal body temperature at a higher level for the time being, just as we put more coal in the furnace to make our houses warmer to protect us from very cold weather. At any rate it is believed that the body can defend itself and put up a better fight against the bacteria and their toxins at an elevated body temperature. It is true that this high body temperature may be injurious to the body tissues and interfere with their function, but it will be equally or more injurious to the bacteria, checking their destructive invasion, and Nature throws all her energies into the struggle of self-preservation even at the tem- porary risk to her own tissues. Formerly the fever accompany- ing these diseases was looked upon as an unmitigated evil and every known means was taken to combat it. It is now recognized that where the temperature is not elevated the prognosis is grave, because it shows that the body is unable to defend itself in this way. To-day, as stated previously, cold sponges, etc., are or- dered, not to reduce the temperature, but to relieve the poisonous effects of the toxins on the nervous system, heart, blood vessels THE CARDINAL SYMPTOMS 143 and other organs. Even in these diseases, however, when the temperature is persistently high, the danger to the tissues is so great, efforts are made to reduce it. Drugs (antipyretics) for- merly used to reduce the temperature are now seldom used be- cause the protective action of the fever is recognized and the danger from a sudden drop in temperature. These drugs also de- press the heart, lower the resistance, and interfere with the pa- tient's recovery. In nursing fevers it must be remembered that the heat-regu- lating centers are so disturbed and overtaxed, their resistance and control so reduced, that conditions which at other times would not affect the temperature, may cause a rise. Great care must be taken to avoid all conditions likely to cause an increased heat-production or a diminished heat elimination. Temperatures Below Normal.—As stated previously, the body must maintain a certain degree of heat in order to carry on the chemical changes in the tissues upon which the mainte- nance of life depends. Life can be maintained for a short time only at a temperature of 95° F. or below. Subnormal tempera- tures may be due to (1) excessive heat elimination, as from profuse sweating, night sweats, a severe hemorrhage, or loss of other body fluids; (2) lessened heat production, as in starvation and lowered vitality. In starvation the patient lives on his own tissues, the muscles and other tissues being used to supply the heat and energy necessary to carry on the vital functions of the heart and respirations, etc. These are spared until the last. (3) Extreme depression of the nervous system as in shock or collapse. All the nerve centers which control and stimulate the functions of the body are depressed and inactive so that the functions of every organ, including the heart and lungs, will be weakened and may be entirely suspended. For the treatment of shock, see Chapter XXXII. The Course of the Fever, or the Temperature Curve.—Fevers usually run a typical course and last for a fairly definite time, characteristic of that particular disease, so we commonly hear it said that "the fever must run its course." In some diseases the "temperature curve," or the diagrammatic representation of the course of the fever on the chart is so characteristic that the diag- nosis is suggested at a glance so that we say this is a typical pneumonia, typhoid, or malaria chart. Fever begins m one of two ways. The onset or invasion (the period when the temperature is rising) may be very sudden and violent, as in pneumonia and scarlet fever. The temperature rises very abruptly, usually accompanied by a chill or in a child by a convulsion (an exaggerated chill), or it may be a gradual onset as in typhoid. The temperature rises higher each day, reaching its maximum in two or more days, and the other symp- toms, headache and backache, etc., become more severe. After the temperature has reached its maximum it usually remains high, though there may be wide variations, for from a few days 144 THE PRINCIPLES AND PRACTICE OF NURSING to two or three weeks. This period of more or less constantly high fever is called the fastigium or stadium. Stadium comes from a Greek word, meaning a measure of distance used in races, and fastigium from a Latin word, meaning the ridge of a roof. The fever will also subside in one of two ways. Like the on- set, it may be very sudden and abrupt, the temperature falling 4 or 5 degrees within a few hours, and reaching to or below nor- mal in from 12 to 24 hours, accompanied by a marked improve- ment in the patient's condition—the breathing and pulse become more normal in rate and character, the patient falls into a sound sleep from which he wakens refreshed, with mind clear, a new being, normal but very weak. Sweating and the voiding of an increased volume of urine usually occur during this period. This is called the crisis, and it is one of the most dramatic and won- derful phenomena in medicine. It occurs in pneumonia, malaria, and scarlet fever, etc. In pneumonia, on examination of the lungs, the congested condition is found to be the same after the crisis as before, but all the other symptoms of the disease, due to the toxins which have been rapidly poisoning the whole sys- tem, have subsided. It is thought that the body has been carry- ing on a tremendous fight against these toxins and has at last succeeded in preparing sufficient antitoxins to overwhelm them. It seems that the chief battle the body has to engage in is that against the toxins produced by the bacteria rather than the bac- teria themselves. Again, it is not so much the drop in tempera- ture, but the subsidence of the symptoms due to the toxic con- dition which marks the improvement or true crisis. The crisis as the word suggests, is a very critical period, the outcome being almost certain recovery or probable death so the patient must be watched very closely. He may go into collapse and die. A sudden fall in the temperature not accompanied by an im- provement in the general condition, but rather by an increase in the pulse rate, with rapid shallow respirations, and increasing weakness, is not a true crisis, but may indicate a severe internal hemorrhage, a perforation of the intestines, or approaching death. In such cases the drop in temperature is a very alarming danger signal and not a sign of improvement. The fever may subside very gradually, as in typhoid, the tem- perature falling step by step in a zigzag manner for two or three days or a week before reaching normal, during which time the other symptoms also gradually disappear. The fever is then said to subside by lysis. Types of Fever.—Fevers in different diseases run a character- istic course and are classified as "constant," "remittent," and "intermittent" according to the diurnal variations. For instance in looking at the temperature curve on the chart in pneumonia you will see that the temperature remains constantly high with only a slight (not more than 2° F.) variation between the morn- ing and evening temperatures. This is a "constant" or "con- tinuous" fever. Sudden changes during a "constant" fever THE CARDINAL SYMPTOMS 145 Reap. Pulse 190 Temp 109 Jan. to______ft______12 13 U is is n IB 96 Temp Resp Stools )ay of Disease 9 10 ____ black, temperature; RED, PULSE; BLUE, RESPIRATION Fig. 6.—Temperature, Pulse and Respiration in Pneumonia. (From Osier's "The Practice of Medicine," D. Appleton & Company, Pub- lishers.') 146 THE PRINCIPLES AND PRACTICE OF NURSING usually indicate complications. If the fever is extensively pro- longed, it also usually indicates complications, frequently tuber- culosis. mje|m|e|m|e|m|e|m|s|m|e|m|e|m|e|m|e|m|e|m|e|m|e|m|e|m|e BLOOD EXAM. WIDAL REACT. ABSENCE OF LEUCOCYTOSIS ANAEMIA REDUCTION OF R. B.C. GREATER REDUCTION OF H/EMAGLOBIN. Fig. 7.—Temperature Chart in Typhoid Fever. (From Farr's "Internal Medicine for Nurses (from Musser)," Lea and Febiger, Publishers.) The temperature curve in -septic fever, remittent fever, and during the invasion and lysis in typhoid, shows a variation of more than 2° F. and usually not less than 3° F. between the i i < < < < * q! a i t i :: <<<£ £ * ■ £ inr° - "^"* ^ ' " m^°" J %\ • :: . - i- 1 \- ^ ~1 I104 >"Y "".§_/ .5 i K._ __ 2103 JL A V -- X-« J .. V- . ~' £102° _i\ * J . S jl 1 .. ^t \ -- £v :: g102 _ H^ V* X 5 jL .- - \- - -j ^ .£ &.. 3 J •_)__£ .. . ^ -A- 1 L^*?y • .. • ^*~*2 ^ v -\ a^U ^^\ V - W? ^ -. = =----...........---\l 96 ■- 0 *w° ■ ___________________________ Fig. 8.—Remittent Fever Chart—iEsTivo-AuTUMNAL Fever. (From Os- ier's "The Practice of Medicine," D. Appleton & Co., Publishers.) THE CARDINAL SYMPTOMS 147 morning and evening temperatures, the lowest point, however, never reaching normal. This is called a "remittent fever." In "intermittent fever" a sudden rise of temperature is followed by a sudden fall to or below normal, the fall usually being ac- companied by profuse sweating. This alternate rise and fall of temperature may occur daily or after the lapse of a regular number of days, as in tertian malaria. The fever accompanying septic conditions, such as advanced tuberculosis, septicemia, and pyemia, is frequently "intermittent," but may be "remittent." A prolonged "intermittent" fever such as in advanced tubercu- losis is frequently described as "hectic." During convalescence from fevers there may be a recrudes- cence or recurrence. The elevation in temperature, etc., may be merely temporary, due to excitement as from the visit of friends, Day Oct. 3 U 5 6 *' a a *' . * a' a' * *' ai a|a a a' . * a a a* aj . a' a a' * * . a ai a^a a' A ° ° !3 3 105 ~m &- -■ «ii° - B -- . .. ± J>Wi .. L . „: ± § in? li03 -i -X H™>° —J- / -A -I- X »102 f r S* ° / \ c 101 1 ^h o • 5 100 . ^\ \ oo° •* u A 4- V v- 4 9o , '. ^ v * d * "^ ^ J wt^ o (f 'T "^ 97 \T _ ** Fig. 9.—Intermittent Tertian Fever—Malaria with Chills. (From Osier's "The Practice of Medicine," D. Appleton & Co., Publishers.) to overfeeding or the first solid food, to constipation, or to some unusual exertion, such as sitting up in bed, or to similar causes. Such a recurrence, however, should receive the most careful at- tention as it may mean a true relapse of the previous disease which must again run its course, or it may indicate complica- tions. The Clinical Thermometer.—The Fahrenheit, self-registering, clinical thermometer is the instrument commonly used in the United States, Canada and Great Britain for measuring the body temperature. The Centigrade scale is used in European coun- tries. The thermometer consists of a glass bulb containing mer- cury, and a stem in which the column of mercury may rise. On the stem is a graduated scale representing degrees of tempera- ture, the lowest degree registered being 95° F., the highest 1KP F., because neither at a body temperature below or above 148 THE PRINCIPLES AND PRACTICE OF NURSING these points can life be maintained. The stem usually has a curved surface which magnifies the lines and figures on the scale, and a flattened back with a sharp ridge which makes it easier to read the scale and also prevents rolling, and so lessens the danger of breakage. The principle upon which the use of the thermometer is based is that mercury expands with heat, the No.SM.TNy^$k*tt^ -V" T»mj> 109 108 107 106 106 101 103 102 101 100 99 95 Pulse Kesp, Fig. 10.—Intermittent Fever of Tuberculosis. (From Osier's "The Prac- tice of Medicine," D. Appleton & Co., Publishers.) height to which the column rises depending upon the degree of heat, which it therefore accurately registers, because in the self- registering thermometer the mercury stays at this height until shaken down. Needless to say, the thermometer must not be used for anything hotter than 110° F., for the mercury would continue to expand and would break the stem. Before using the thermometer, see that the mercury does not register above 95° F. To shake the mercury down grasp the thermometer securely by THE CARDINAL SYMPTOMS 149 the upper end (never hold it by the bulb), flex the hand, and give a quick sudden movement of the wrist as when snapping the fingers or cracking a whip. Do not shake the mercury below 95° F., as it may be difficult to get it up again. Be careful not to let the thermometer fall or strike against anything. The body temperature may be ascertained by placing the ther- mometer in the mouth, the axilla, groin, rectum, or vagina. The temperature sought is that of the interior of the body uninflu- enced by contact with clothing, air, or moisture, etc., so the thermometer must be placed where it can be completely sur- rounded by body tissues and where there are large blood vessels and a free circulation of blood near the surface. The nearer these conditions are approached, the more accurate the tempera- ture taken will be. In taking the temperature by mouth, place the end of the ther- mometer containing the mercury under the tongue, because here it will be close to large arteries. See that the lips are kept tightly closed and that the patient breathes through the nose only. The mouth should be thoroughly clean. Leave the thermometer in this position until the mercury reaches a constant height, but do not leave it longer than necessary. The time will depend upon the thermometer used and varies from two to five minutes. The best grade of thermometer will register in one-half minute, but as the mouth contains air derived from the exterior, the lips must remain tightly closed for at least two minutes to allow it to warm up to the body temperature. The normal temperature of the mouth is 98.6° F. When Not to Take the Temperature by Mouth.—The mouth is the most convenient place for taking the temperature, but should not be used immediately after the patient has had hot or cold drinks or food or when she has been breathing through the mouth, or when having cold or hot applications applied to the face or throat. Do not use this method when the patient has difficulty in breathing from any cause, or when the mouth cannot be closed for the required time, for instance, when the patient has an acute cold in the head or inflammation of any part of the respiratory tract, with obstruction, sneezing, or coughing, etc.; or after an operation on the nose, when the nose is "packed" with gauze, and also when the mouth cannot be kept closed from extreme weakness. It must not be used when the mouth is dry, parched, inflamed, or covered with sordes; it must never be used for children, for restless, nervous, delirious, unconscious, hysteri- cal or mentally ill patients because of the danger of biting and breaking the thermometer and swallowing the glass and mercury. The mercury if swallowed would probably do no harm, because in its metallic form it is inert, that is, it does not combine with the tissues of the body in any way, therefore has no influence upon them and can do no harm, but would probably be dis- charged through the intestines. The broken particles of glass, however, if swallowed would do harm, so if a thermometer should 150 THE PRINCIPLES AND PRACTICE OF NURSING accidentally be broken remove all particles of glass from the mouth. If any glass has been swallowed, eating bread or some other soft food will help to prevent injury to the lining of the alimentary tract. Report the accident at once to the doctor, who, as a precautionary measure, will probably prescribe the white of egg, which is largely albumin. Albumin is the anti- dote for mercury and renders it harmless. It forms a coating around each molecule of mercury so that it cannot come in con- tact with the tissues and it also combines with it chemically, forming a new harmless substance. If the temperature taken by mouth seems unusually low,"or if there is any doubt of its accuracy, take it over again, or take it by rectum, or take it with another thermometer. The Axillary Temperature.—The temperature is sometimes taken by axilla when it cannot be taken by mouth because it is convenient, hygienic and occasions little discomfort or exertion to the patient. Before placing the thermometer in position see that the axilla is free from moisture or perspiration, but do not rub the part because the friction may increase the temperature and make it inaccurate. See that the bulb is placed securely in the axilla and that it is completely enclosed by the body tissues by placing the arm over the chest with the fingers on the opposite shoulder. Do not allow the clothing to come in contact with the thermometer. It must remain in position ten minutes. For infants, the groin temperature is sometimes taken. The thigh must be well flexed over the abdomen. Ten minutes are required for registration. The axillary and groin temperatures are usually about one- half degree lower than that of the mouth. The rectal temperature is the most reliable and is generally used for very ill or toxic patients, for infants, children, restless and delirious patients. This method cannot be used after rectal operations, or when the rectum is diseased, inflamed or not per- fectly clean. Bacteria are always present in fecal matter in which they cause decomposition or combustion with the produc- tion of heat. The presence of fecal matter would therefore in- crease the rectal temperature possibly one degree higher than it should be. Oil the bulb before inserting it to prevent irritation —irritation is not only a discomfort, but it draws an increased supply of blood and therefore heat in the part. It also stimu- lates the muscles of the rectum to expel the thermometer. In- sert the bulb about two inches. The rectal temperature is usually from one-half to one degree higher than that by mouth, because it is a closed cavity less influenced by external conditions and because in the rectum there is a large plexus of veins close to the surface lining and therefore a large volume of warm blood. Never leave children or restless, delirious or hysterical patients alone with a thermometer, for their restless movements are apt to displace or break it. Hysterical patients, and sometimes others, also, occasionally try to mislead the nurse into thinking that THE CARDINAL SYMPTOMS 151 their temperature is elevated by "sucking" the thermometer or holding it on a hot-water bag or in hot fluids, etc. The Care of Thermometers.—Thermometers, whether used for mouth or rectal temperatures, should be rendered scrupu- lously clean and free from infection after use by washing thor- oughly in cold water and allowing them to stand in an antiseptic solution (usually bichloride of mercury 1 to 2000) long enough to disinfect them. This is necessary both for esthetic reasons and also to avoid carrying infection to either the mouth or rec- tum. Those used for rectal temperatures should be marked and kept separate. In hospitals, thermometers with colored glass bulbs are usually used for rectal temperatures. If possible each patient should have a separate thermometer but in hospitals for adults this is seldom practicable or possible. Infectious diseases are so prevalent among children and infants, and children are so susceptible to infection that separate thermometers are essential. In infectious diseases in adults separate thermometers are also essential. A separate jar of vaseline should also be kept for lubricating rectal thermometers used in infectious diseases. All thermometers should be tested and compared at regular intervals with a standard thermometer, because the glass gradu- ally contracts so that, after a time, the readings are inaccurate, being slightly too high. CHAPTER XIV THE CARDINAL SYMPTOMS (Continued) THE PULSE The pulse is the distention or pulsation of the arteries pro- duced by the wave of blood forced through them by the con- traction of the left ventricle during systole. This contraction is called the heart-beat. Each time the heart beats it forces about 3 ounces of blood into the already filled aorta. This causes an increased pressure of blood which (as the blood is confined within closed tubes) drives the column of blood onward toward the capillaries. The increased volume of blood also exerts a lateral pressure, that is, an increased pressure against the walls of the arteries, which, being highly elastic, stretch or expand, the de- gree of expansion depending upon their elasticity and tone. This pressure and expansion pass from point to point in the elastic wall as the column of blood moves onward so that it proceeds in the form of a wave—the "pulse wave." This pressure and rise of the artery may be felt by placing the fingers along an artery which runs near the surface. This is the "upward curve" seen on "pulse tracings," due to the impulse caused by the heart- beat. If this were the only provision for the circulation of the blood, it would cease to flow when the heart-beat was completed and so the supply of blood (with food and oxygen, etc.) brought by the capillaries to the tissues would be very irregular, either a feast or a famine. The walls of the arteries, however, are highly elastic and contain muscles which are also elastic so that like all elastic tissue the arterial walls offer a certain resistance to stretching or pressure made upon them and strive to resume their original size. When the heart stops contracting the semi- lunar valves are closed, and no more blood flows into the arteries, their elastic walls recoil and press constantly and steadily upon the blood within them so that it is again driven onward. As this recoil proceeds all along the arteries until the next heart- beat, the blood is kept constantly moving through the capillaries and veins—the impulse or beat of the heart is followed, as it were, by the impulse or beat of the arteries. This steady recoil of the arteries is the downward curve of the pulse when the artery is felt to recede from the examining finger. The upward curve, corresponding to the systole or working period of the heart, and the downward curve, corresponding to the diastole, or resting period of the heart and produced by the recoil of the elastic 152 THE CARDINAL SYMPTOMS 153 arterial walls, constitute the pulse. Whatever interferes with the function of the heart, with the volume of blood or with the elasticity and contraction of the blood vessels, will cause a change in the pulse. The Importance of Accuracy in Taking and Recording the Pulse.—Feeling, or "taking" the pulse is, therefore, a quick, con- venient, and (in the hands of an experienced person) a reliable means of gaining valuable information concerning the condition of the heart, blood vessels, and circulation. The heart is a vital organ. Information concerning it is, therefore, of vital import- ance: The life of every cell, the function of every organ, life itself, depend upon a constant circulation of blood through the capillaries and this depends not only upon the heart, but upon the elasticity and tone of the blood vessels. Information con- cerning them is therefore also of vital importance. The heart and blood vessels are controlled or regulated by the nervous sys- tem so that anything which interferes with its function (such as injury or pressure upon it), or which stimulates it—excite- ment, anger, cold, drugs, toxins, or poisons, etc.—or which de- presses it—worry, shock, collapse, drugs (ether, alcohol, etc.), toxins or poisons,—will be indicated by a change in the pulse. Again as the circulation is maintained merely to meet the needs of the body (the heart even quickening its beat to meet the added slight exertion required of the sitting over the reclining position), any abnormal condition of the body will be responded to by a change in the heart and blood vessels, and therefore, in the pulse. Abnormal conditions in the heart and blood vessels themselves will, of course, cause a change in the pulse, so that the pulse gives valuable information concerning the heart, and the patient's general condition also. In diseases such as the acute infections the pulse is a valuable indication of the effect of the disease on the patient, his resistance to it, the prognosis, and the treatment advisable. In fevers, even when the temperature is very high, if the pulse shows the heart and blood vessels to be holding their own, the prognosis is favorable. In accidents and other emergencies, either surgical or medical, feeling the pulse tells at once, without loss of valuable time, the degree of shock and the need for stimulation, and so, in many instances, an understanding of the pulse may be, and often is, a means of sav- ing life. The heart is one of the last organs to give out. It has been found beating even after death, so that the pulse is a valuable indicator of the prognosis and treatment as well as of the diag- nosis. Symptoms of failure of the heart are always serious. A few years ago—not more than fifty—the pulse was the only means available of studying the condition of the heart, so that both physicians and nurses became wonderfully expert in read- ing and understanding it. Today, while there are instruments which record more accurately certain characteristics of the pulse, it is said that the study of the pulse by feeling the artery with 154 THE PRINCIPLES AND PRACTICE OF NURSING the finger is, and always will be, a very important factor in the diagnosis, prognosis, and treatment of disease. For the nurse "taking" the pulse will always be one of her most important duties, and she should remember that the life of the patient may often depend upon her intelligent and accurate observation and recording of this most important symptom. This requires a great deal of experience and as experience comes only with practice, she cannot begin too early to study the characteristics of the normal pulse, to compare the pulse in disease with the normal, and to study the pulse in relation to the disease in which it occurs. An understanding of the pulse depends upon a thorough under- standing of the circulatory system which may be attained from a study of the text-book on anatomy and physiology supplied to students. The pulse of a patient is always taken twice during the twen- ty-four hours, much more frequently, every four hours, in some cases, and is constantly watched when the patient's condition is critical and when a change either for better or worse is expected. It is also taken before, during, and after many nursing proced- ures or treatments requiring exertion, mental or physical strain, or pain, or which are apt to affect the heart and circulation either directly or through the nervous system which controls it. For instance, it is taken when the patient is sitting up for the first time after an operation or a long illness, or when very cold or hot baths or packs are given, or an aspiration of a body cavity such as the pleural, the abdominal, or pericardial cavity, or the spinal cord. Where the Pulse can be Taken.—Any large, superficial artery which rests directly upon a bone against which it can be com- pressed can be used for taking the pulse. The radial artery is usually used because it is most convenient, accessible and com- pressible, as it lies just underneath the skin of the inner surface of the wrist and directly over the radius. When for any reason the wrist is not accessible, for instance, when it is swathed in dressings, a plaster cast, splint or restraining straps, the temporal, facial, carotid, femoral, or dorsalis pedis arteries must be used. Each of these, except the carotids, may be compressed against a bone, and felt at the points indicated in the accompanying diagram. The temporal artery may be used sometimes with less dis- turbance to the patient and must be used during such treat- ments as a hot or cold pack when the body is completely wrapped in blankets or sheets. The carotid arteries, although not rest- ing on a bone, are large, near the surface, and quite close to the heart, so the pulsations derived from the heart-beat may be felt here when imperceptible at the wrist. The pulsations, in some diseases, may be seen and counted in the temporal and carotid arteries without touching the patient. The pulse may sometimes be felt also in the femoral artery when imperceptible in the wrist because it is larger and nearer to the heart. It is said also that THE CARDINAL SYMPTOMS 155 the blood-pressure can be more accurately judged in the femoral artery. When possible, use the same artery each time. Arteries differ in size, therefore in the volume and velocity of the blood Facia] Innominate Heart Aorta Common iliac External iliac Internal iliac Temporal External carotid Common carotid Subclavian Aorta Axillary Brachial Radial Ulnar Palmar arch Femoral —Popliteal Anterior tibial Posterior tibial Dorsalis pedis Fig. 11.—The Principal Arteries of the Body Showing Where the Pulse May Be Taken. (From Morrow's "Immediate Care of the Injured," W. B. Saunders Co., Publishers.) flowing through them, and also in the structure of their walls, the largest having more elasticity, the smaller being more muscu- lar. You have to know what the artery feels like normally in 156 THE PRINCIPLES AND PRACTICE OF NERSIN( J order to be able to detect slight but important differences in the pulse. How to Feel the Pulse.—Place the tips of three fingers on the artery, exerting just enough pressure to make the pulse most distinct. Never use your thumb because it also has a pulse and this might be confused with that of the patient. Three fingers (the first, second, and third) are used because, as you remember, the blood travels in the form of a wave, alternately rising and falling, and it is the character of this wave which we must study. Again, certain characteristics are studied by compressing the artery with the other two. Count for a full minute in order to study the rhythm or regularity of the pulse. Before starting to take the pulse, see that the patient is in a comfortable position and that the part (the arm, etc.) is at rest and supported. Do not take it immediately after the patient has been subjected to any physical exertion or any painful expe- rience, either mental or physical. In a nervous, excitable, or self-conscious person the mere act of taking the pulse may greatly increase its rate and alter its character. The patient should have his attention diverted, and your fingers should remain in position until after the excitement, etc., has subsided. At any time do not be in a hurry; be sure that you yourself are calm and in a condition to give thoughtful attention to what you are doing; feel the artery, get used to it before starting to count, or study the character of the pulse. When taking the pulse at the wrist, the arm should be sup- ported and the forearm semipronated as the pulse is then more easily felt. When counting the pulse of a patient for the first time, always examine both radial arteries because frequently one may be abnormal in its size or course or may be diseased, in- jured, or subjected to pressure at some point so that the pulse in that artery would be misleading. Verify your readings by using other arteries. When in any doubt, ask a more experienced nurse to take the pulse and check your results before charting. Chart the pulse, or at least record it on paper at once to avoid errors. What to Note when Taking the Pulse: 1. The condition of the wall of the artery. 2. The tension or compressibility of the artery. 3. The volume of the pulse, the size and shape of the pulse wave. 4. The rate of the pulse. 5. The rhythm of the pulse. The Normal Pulse.—-The artery should feel firm, round, smooth, elastic, and straight (the temporal artery is twisted or tortuous), the tension should be moderate, and the pulse not obliterated by moderate pressure. The pulse wave should be medium, rising and falling neither abruptly nor abnormally slowly; the artery should be just perceptible between the beats; each successive beat should be of equal force; the intervals be- tween beats should be equal in length and the number of beats THE CARDINAL SYMPTOMS 157 per minute should be normal for the particular individual de- pending upon the age and sex, etc. The characteristics of the normal pulse and the abnormalities which may occur in disease may be more clearly understood by a study of a "pulse tracing" of a normal pulse as recorded by the sphygmograph. This is an instrument with which graphic tracings may be made showing a magnified record (magnified because otherwise too small to be recorded) of the pulsations of the artery made by the "pulse wave," thereby recording regu- larities or irregularities in it which may be studied at leisure. It consists of a button which is placed over the artery with mod- erate pressure. The button is attached to a steel spring, which, in turn, is attached to a lever with a writing style which records the tracings of the rise and fall of the artery on smoked or white paper. The upward curve (see figure 12) is called the primary curve and represents the expansion of the artery caused by the sudden inflow of blood during the forceful contraction of the left ven- Fig. 12.—Sphygmographic Tracing of a Normal Pulse. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Pub- lishers.) tricle—the heart-beat. This measures the force of the heart- beat. The upward curve is normally smooth. In the downward curve there are several waves represented (pulsations of the artery), the one which concerns us being the one in the middle of the curve. It is called the dicrotic wave because in the middle {di meaning two), and because, in certain diseases, this dicrotic wave is so exaggerated and pronounced that it gives the sensa- tion of a double beat of the heart. The slight wave preceding the dicrotic is called the predicrotic, the one following the post- dicrotic. These need not concern us. Normally these pulsa- tions or waves are all imperceptible to the examining finger. In some diseases the dicrotic wave is so pronounced, the pulse is spoken of as the "dicrotic pulse," and it is necessary that you should recognize and understand it. You will notice that the downward curve is much more gradual than the upward curve. This is because the upward curve is due to the forceful heart-beat while the downward curve is brought about entirely by the elastic recoil of the walls of the artery. The upward curve represents the systole of the heart when blood is streaming into the arteries and the artery rises against the fingers. The downward curve represents the diastole of the 158 THE PRINCIPLES AND PRACTICE OF NURSING heart. The semilunar valves are closed, blood has ceased to flow into the aorta, the elastic walls are returning to their original size, pressing constantly and steadily on the blood and sending it onward, and the artery is felt to fall away gradually from the fingers. The "dicrotic wave" is caused by the closure of the semi- lunar valves. The elastic wall of the aorta as it recoils drives the blood in two directions—onward and back against the closed semilunar valves against which it strikes with considerable force, depending upon the original force of the heart-beat. From this wall of resistance and sudden check to its flow it rebounds and this rebound causes the expansion of the artery called the dicrotic wave which, however, as stated previously, is not nor- mally perceptible to the examining finger. I. The Condition of the Wall of the Artery.—Normally in young persons when the flow of blood is shut off in the radial artery with one finger, the empty artery beyond cannot be felt. As one grows older, however, the arteries lose their elasticity be- cause of the formation of fibrous tissue in the wall which makes it stiff, thicker, less elastic, and in old age the artery may be leathery, rigid, hard and unyielding. This is a form of arterio- sclerosis, "hardening of the arteries," more apt to develop in those who have done hard muscular work or who have led a life of severe mental strain and worry. Overeating and severe men- tal or physical strain are important factors. Arteriosclerosis oc- curs also as a result of disease such as Bright's disease and gout. The artery feels like a rubber tube which can be rolled under the fingers when empty and stands out visibly between the heart-beats. In more advanced arteriosclerosis, the arteries seem to be stretched in length so that in the limited space they are forced to become twisted, tortuous, or "snake-like." In still more advanced arteriosclerosis the walls become calcified, that is, calcium salts are deposited in small plates (like pieces of egg- shell) so that when you run the finger along the artery the plates are felt as a series of beads. The artery then feels like a cord and is so rigid that it is described as a "pipe-stem," or is said to be like a "goose's neck." Such an artery may be absolutely incompressible and sometimes little or no pulse can be felt. The circulation depends to a large extent upon the elasticity of the arteries, so that when this is lacking the whole body must suffer. The health and prolongation of life depend upon the cir- culation, so that a common saying is that "a man is as old as his arteries." The heart itself will be under a tremendous strain because it has to work much harder to overcome the resistance of the rigid arteries. Normal arteries aid the heart in the cir- culation of the blood. Such changes in the walls of the arteries and in the heart will have a marked effect upon the pulse. The downward curve is less gradual than normal, depending upon the degree of rigidity. In old age the artery falls away rather sharply from the finger and as the pulse in old age is usually slow (the interval being THE CARDINAL SYMPTOMS 159 long between the beats), the artery feels "empty" between the beats. II. The Tension or Compressibility of the Artery.—The blood in the arteries is confined "under pressure," the degree of pressure depending to a large extent upon the stretching or tense- ness, the relaxation or contraction of the elastic, muscular walls of the arteries. When the muscles are contracted the size of the arteries is diminished so that more resistance is opposed to the flow of blood within them, and it is said to be under tension or pressure—the pressure being the force of blood against the blood vessels, and the tension, the resistance opposed to it by the art- eries. The walls of the large arteries are both elastic and muscu- lar and exert a constant pressure and resistance to the blood within them. The small arteries, the arterioles, are chiefly mus- BBBBPBEB Fig. 13.—Sphygmographic Tracing of the Pulse of a Man Aged Seventy- four Years. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Publishers.) cular and are normally in a state of tonic contraction so that they hold back the blood, keeping it under a normal, fairly constant pressure in the arteries and regulating the amount flowing through the capillaries into the veins. By this constant pressure the flow of blood is changed from a jerky, intermittent flow, caused by the heart-beat, to a steady, continuous stream through the capillaries and veins (otherwise the blood would flow during the heart-beat only) and the blood-pressure is kept fairly nor- mal and constant. The Importance of Maintaining a "Normal Blood-Pressure."— Life depends upon a free circulation of blood and the circulation depends upon the fact that there are different degrees of pres- sure in different parts of the circulatory system—the arteries, arterioles, capillaries and veins. The pressure is highest in the large arteries because, being near the heart, they feel the full force of the heart-beat, and being few in number, the space for the flow of blood is limited. The pressure is less in the small arteries, and still less in the arterioles, because they are more remote from the heart, are less influenced by the heart-beat and because, while they are smaller in size, they are so numerous the blood has more room, and is spread out over a larger area, is not so confined, and is therefore under less pressure. The pressure in the capillaries is greatly reduced because, while much smaller than the arteries, they are much more numerous in number, the space over which the blood can spread is so wide it is as though 160 THE PRINCIPLES AND PRACTICE OF NURSING it were flowing from the confined narrow borders of a river into a broad lake. As previously explained, the force of the heart beat is entirely lost in the arterioles whose muscular walls change the intermittent flow caused by the heart-beat into a steady, constant stream. The heart-beat or the pulse is therefore not perceptible in the capillaries normally. There is no "capillary pulse" except in pathological conditions. The flow of blood in the capillaries (which are in contact with all the cells of the body) is therefore very slow and continuous, so that the cells are constantly supplied with oxygen and food and waste products are as constantly removed. The nutrition and life of the body depend upon this factor. The pressure in the veins is still lower than that in the capillaries. The impulse in the heart-beat has been entirely lost or has been regulated and converted by the arterioles into a steady stream. The veins are also twice or thrice as large as the arteries, giving much more room for the blood and therefore lowering the pressure. In the large veins near the heart the pressure is negative. This dif- ference in pressure can readily be demonstrated by cutting an artery, capillaries, or a vein. When a large artery is cut the blood spurts out in jerks with great force; from a small artery with much less force, from tissues in which the capillaries are cut the blood "oozes" out from the whole surface, and the tissues are said to "weep"; from a vein the flow is steady and continuous with all evidence of the pulse gone. A "venous pulse," like the "capillary pulse," is only present in pathological conditions. It refers to the pulse observed in the large veins near the heart such as the jugular—it gives the beat of the auricles. The blood naturally flows from a point of high pressure to a point of lower pressure, so that by a constant uniform blood- pressure maintained in the arteries the blood is made to flow from the arteries constantly through the capillaries and veins back to the right side of the heart, so that it can be sent on to the lungs to be purified and back to the left side of the heart to be again distributed to the whole body. The blood must be brought back to the heart, otherwise it cannot be purified and the heart would have nothing to pump on to the arteries. Anything, then, which interferes with the maintenance of the normal blood-pressure will interfere with the vital function of the heart and with the health of the whole body. It is important to be able to recognize changes in the pulse which indicate an abnormal blood-pressure. The blood-pressure depends upon three factors—the elasticity and contraction or relaxation of the arteries, the volume of blood, and the force of the heart-beat. The tension and the blood-pressure can be fairly accurately measured by the force with which the pulse strikes against the finger and the degree of pressure necessary to obliterate the pulse, that is, to prevent the pulse wave from going further along the artery. This is called its compressibility. It is tested by com- THE CARDINAL SYMPTOMS 161 pressing the artery against the bone with one finger and with the other fingers feeling the artery beyond. The tension and blood-pressure may be "high" or "low." The Pulse of High Tension or Hypertension.—The tension Fig. 14.—Diagrams of Pulse. 1. Normal; 2, Low Tension and Soft Pulse; 3, High Tension and Hard Pulse; 4, Soft Pulse Fully Di- crotic; 5, Very Soft Pulse and Hyperdicrotic. (Landois and Stirl- ing.) (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Publishers.) will be "high" when the arteries are contracted and the heart is beating with some force. All muscles when in a state of con- traction feel firm and hard so that the pulse of high tension feels "hard" to the touch. It is difficult and sometimes impossible Fig. 15.—Sphygmographic Tracing of a Hard (High Tension) Pulse (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publish- ing Co., Publishers.) to compress a "high tension" pulse. Between the beats it feels "full" and the artery may be felt as a distinct cord which can be rolled over the bone by the fingers. The expansion of the artery caused by the upward curve is Fig. 16.—Sphygmographic Tracing of a Hard (High Tension) Pulse. (From Cabot's "Physical Diagnosis," Wm. Wood & Co., Publishers.) moderate or low, the downward course is slow and more gradual than normal with little or no dicrotic wave. The Causes of Hypertension.—Whatever increases the force 162 THE PRINCIPLES AND PRACTICE OF NURSING of the heart-beat and the contraction of the arteries may cause a high tension either temporary or permanent. Exercise and emotions may cause a temporary increase in tension—sometimes in excitement or anger the vessels may be seen standing out like cords. This must be remembered in caring for a patient with a high blood pressure or hypertension, because if the vessel walls are diseased even a slight added increase may be sufficient to rupture the vessel in some place such as the brain, where it may be weakest, and cause a fatal hemorrhage. A cold bath will also raise the tension because cold stimulates the nerve centers in the brain which causes contraction of the arteries and also stimulates the heart. For this reason "cold tubs" and "cold sponges" are given in typhoid in order to tone up or stimulate the circulatory system—in typhoid the blood vessels are relaxed and the tension is "low." Chills and convulsions also raise the tension. Increase in the intracranial pressure (around or within the brain), due to a cerebral hemorrhage, with pressure from the accumulated blood, or to an increase in cerebro-spinal fluid as in meningitis, or to pressure from a bone in fracture of the skull, raises the tension. Chronic nephritis, arteriosclerosis, and exoph- thalmic goiter cause a permanent high tension. Drugs which stimulate the heart and the contraction of the arteries—caffeine, strychnin, adrenalin, pituitrin—increase the tension and are fre- quently given for this effect. It is very important to be able to recognize a "high tension" pulse, for it may be an early symptom of a serious functional disturbance in the kidneys or blood vessels or of some other serious brain lesion. The Pulse of "Low Tension" or Hypotension.—With the mus- cular walls of the arteries are relaxed, little resistance is offered to the blood so that the tension and blood-pressure in the arteries are "low." This greatly interferes with the circulation because during diastole, when the blood in the arteries is not being im- pelled onward by the heart-beat, the relaxed arterial muscles fail to contract and keep the blood moving. The circulation becomes sluggish, the tissues are ill-nourished and clogged with wastes, the blood collects in the veins so that they become congested, less blood returns to the heart to be sent to the lungs to be puri- fied, and as the heart has not sufficient blood to keep the tissues supplied at its normal rate it beats more rapidly, but the beats have less force and may be weak and feeble. In very severe cases so much blood may collect in the large veins that death may result. Muscles when relaxed feel soft or flabby so the pulse in "low tension" feels "soft" to the touch. The artery is easily com- pressed, collapses or falls away suddenly from the finger because it lacks tenseness or tone—seems to have no life in it. Between the beats it feels "empty" and the artery can scarcely be felt or even not at all. The "Dicrotic Pulse"—The dicrotic pulse is a sign of low THE CARDINAL SYMPTOMS 163 tension. Figure 17 illustrates a "pulse tracing" in "low tension" —the dicrotic wave (in the middle of the downward curve) is very marked. The upward curve rises "sharp" and "high." The artery strikes the finger quickly and sharply. The downward curve is also sudden, the artery falling away quickly. The pulse may seem strong from the way in which the artery strikes the fingers, but little force is needed to expand the weak, relaxed artery. For the same reason the dicrotic wave is always marked in low tension, particularly when the heart-beat is forceful. Fig. 17.—Sphygmographic Tracing of a Soft (Low Tension) Pulse. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publish- ing Co., Publishers.) When the blood is driven into the artery with force and the arterial wall collapses, driving the blood against the closed semi- lunar valves, the rebound will also come with force against the weak wall of the artery, expanding it so markedly that the di- crotic wave (normally imperceptible) will be quite exaggerated and easily perceptible to the finger. When the tension is low as in typhoid and other acute infections, the dicrotic wave feels like a second weak beat and the pulse is called a "dicrotic pulse." It must not be counted as a pulse or beat. Low tension occurs as the result of anything which destroys the tone and causes dilatation of the arteries. For instance, food, Fig. 18.—Sphygmographic Tracing of a Dicrotic Pulse. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Pub- lishers.) moderate exercise, a warm bath or hot pack will lower the ten- sion. Other causes of low tension are poorly nourished muscles of the heart and blood vessels, as in pernicious anemia and low- ered vitality from any cause; the infectious diseases—typhoid, pneumonia and tuberculosis, etc.—in which the toxins poison and weaken the muscles of the heart and blood vessels and also de- press the centers in the brain which normally stimulate their contractions; a severe hemorrhage; surgical shock or collapse in which the vessels are dilated and the blood congested in the large 164 THE PRINCIPLES AND PRACTICE OF NURSING veins; Addison's disease, a disease of the adrenal glands in which there is a lessened secretion (adrenalin) which in the normal body aids in maintaining muscular contractions. Certain drugs —aconite, amyl nitrite, and nitroglycerin, lower the tension either by depressing the action of the heart or dilating the blood vessels. In high blood-pressure they are used to lower the tension. Prolonged low tension is very serious so it is important to recognize the pulse in order that methods may be taken at once to raise the tension by stimulating the heart and the contraction of the blood vessels with drugs and treatments. Fig. 19.—Method of Taking the Blood-pressure with Mercer's Type of Riva-Rocci Sphygmomanometer. (From Cabot's "Physical Diagno- sis," Wm. Wood & Co., Publishers.) The sphygmomanometer is an instrument for accurately meas- uring the blood-pressure by determining the exact pressure nec- essary to compress and obliterate the pulse. There are several forms of apparatus which may be used. The normal blood-pressure is as follows (Cabot): Systolic (blood is streaming into the arteries) 110-135 mm. Hg.; Diastolic (the arteries are closed off from the heart) 60-90 mm. Hg. The blood-pressure is less in women than in men and lower still in children—90 to 110 mm. Hg. and in children under two years 75 to 90 mm. It is usually higher in old age. In disease, for in- stance, in nephritis, it may be 200 mm. and more. THE CARDINAL SYMPTOMS 165 III. The Volume of the Pulse^the Size and Shape of the Pulse Wave.—The pulse is described as "large," "big," "full" and "bounding," or "small," "feeble," "weak," "flickering," or "thready," depending upon the size of the wave against the fin- ger, in the sphygmograph, depending upon the height of the up- ward curve. The size of the wave depends upon the force of the heart-beat and the tenseness or relaxation of the arteries. If the arteries are relaxed the pulse wave will be high and the pulse will feel "big," "large," or "full," and if also rapid in rate (the beats following each other in quick succession), it is described as "bounding." This pulse occurs in conditions with "low ten- sion." If the arteries are contracted and small, the pulse wave will be "small" and the pulse will feel "small"—in "high ten- sion" ("hard" pulse) the pulse will feel "small" and sometimes so "hard" that it is described as "wiry." When the heart-beat Fig. 20.—Pulse Tracing in Aortic Regurgitation Showing Its Collapsing Character. (From Cabot's "Physical Diagnosis," Wm. Wood A Co., Publishers.) is weak the pulse will feel "small," "weak," "feeble," so that it can scarcely be felt or even not felt at all, or it may be so small as to feel like a little thread, or "thready." This occurs in col- lapse, after a severe hemorrhage, and frequently when death is near. When the pulse is both feeble and rapid the condition of the patient is always serious. If the tension is normal, the pulse wave indicates the force and the condition of the heart. The Shape of the Pulse Wave.—The pulse may be "quick" or "short," that is, the wave rises and falls quickly. The pulse wave strikes the finger quickly and recedes quickly. This oc- curs in a "soft" or "low tension" pulse. It is frequently called an "ill-sustained" pulse. It indicates a weakened or diseased heart or weakened blood vessels, or both. It occurs to a marked degree in aortic regurgitation, that is, when the valves leading from the heart to the aorta are imperfect and do not close prop- erly so that they allow the blood from the aorta to "leak" back into the left ventricle when the elastic walls of the aorta recoil. The pulse strikes against the finger sharply and with great force 166 THE PRINCIPLES AND PRACTICE OF NURSING because the heart tries to overcome the defect in its valves and to empty itself completely. On account of the leakage (the blood being able to flow in two directions) the aorta empties itself so quickly, the artery falls away very quickly from the finger ahd feels "empty" between the beats. This is called the "water-hammer' or Corrigan's pulse. The pulse feels "large," "full" and "quick." It may be observed in the carotid arteries as a sharp rising and falling. The pulse may be "long" or "slow," that is, it rises slowly and gradually, pauses and falls gradually. This occurs in aortic stenosis, in which the valves leading from the heart to the aorta open during systole only sufficiently to allow a small stream to Fig. 21.—Sphygmographic Tracing of Pulse in Aortic Stenosis Showing Infrequent Rate, Small Pulse, Slow Rise and Fall. Compare with the normal pulse wave and with that of aortic regurgitation. (From Cabot's "Physical Diagnosis," Wm. Wood & Co., Publishers.) pass through, so that the left ventricle is a long time in emptying itself. This pulse is a "hard," "high tension" pulse. The "dicrotic pulse" wave, the "low tension," and the "high tension" pulse waves have been described. IV. The Rate of the Pulse.—(Howell).—The heart lives and works only to supply the needs of the body—the work of the heart is summed up in the heart-beat. These needs vary accord- ing either to changes in the conditions surrounding the body or in the condition of the body itself and the heart-beat changes in rate (and force) promptly and unfailingly as the need arises. The pulse is normal only when the mind and body are in a state of rest. There are wide variations in the'normal pulse rate in different individuals which may be peculiar to .the individual or may occur in families. For instance, while the normal pulse rate for an adult varies from 70 to 80 beats per minute, in some individuals the normal rate may be 50, while in others the normal rate may be 90. Variations of the Pulse Rate.—The rate of the heart-beat varies with sex, size, and age. In man the average pulse rate is 70; in woman 75 to 80. In tall people the pulse rate is slower than in short people of the same age. It has been found that the pulse rate in small animals is higher than in large animals as illustrated in the following pulse rates: The elephant 25 to 28; the horse 36 to 50; sheep 60 to 80; the dog 100 to 120; rab- bits 150; mice 700. THE CARDINAL SYMPTOMS 167 The pulse rate varies with age, gradually diminishing from birth to old age, increasing somewhat again in extreme old age, thus: (Halliburton) Before birth the average number of pulsations per minute is 150. Just after birth the average number of pulsations per minute is from 140 to 130 During the first year ...................... During the second year .................... During the seventh year ................... During the fourteenth year (puberty) ....... In adult age .............................. In old age ................................ 130 to 115 115 to 100 90 to 85 85 to 80 80 to 70 70 to 60 In old age the pulse rate is normally slower, therefore a rapid pulse is more serious in the old than in the young. In extreme old age the rate may be increased, 75 to 80, as the action of the heart approaches the condition of infancy, as old age does in so many other ways. The pulse rate also varies (increasing or decreasing) in re- sponse to sensations or messages sent along sensory nerve fibers from all parts of the body to the nerve centers in the brain which control or regulate the action of the heart through the accelerator and inhibitory nerve fibers. The accelerator nerve fibers (from the sympathetic system) increase the rate, while the inhibitory fibers act as the reins which check or slow the rate. Messages are constantly being sent over these wires to which the heart in- stantly responds so that the needs of the body are met without loss of valuable time. For instance, through these nerves the emotions—apprehension, fear, surprise, joy, excitement, antici- pation, anxiety, worry, anger—have a powerful influence on the action of the heart. Some people instinctively place their hands over their heart when under the influence of strong emotion caused perhaps by unexpected news whether of joy or sorrow. In pictures and statuary, also, emotion is expressed in this way. Common expressions in our language, "died of a broken heart," "down-hearted," "heart jumped for joy," or "stopped beating with fright," also show that the effect of the emotions on the heart is a matter of common experience. Messages are also constantly being sent from internal organs, the stomach and intestines, etc., which have a marked influence on the pulse rate. After meals the pulse is increased both in rate and force. Messages from the heart itself are sent along sensory fibers to these nerve centers which in turn regulate it so that in diseases of the heart the heart-beat can be increased in rate and force. Messages are also being sent from nerve endings in the skin to the centers which regulate the heart. A cold bath or water "dashed" on the face will first quicken, then slow and steady the heart-beat and raise the tension; a hot bath will quicken and lower the tension. In the same way a mustard 168 THE PRINCIPLES AND PRACTICE OF NURSING paste applied over the region of the heart will stimulate its action. Through these nerve centers and nerves, severe or pro- longed pain in any part of the body will have a marked effect on the pulse rate. The rate of the pulse varies with the blood-pressure. When the blood-pressure in the arteries is low the pulse rate increases in order to increase the output of blood and so raise the pressure. Thus in surgical shock in which the blood-pressure is low, the pulse rate is very rapid. When the blood-pressure is high, the rate of the pulse is decreased. In old age the blood-pressure is higher and the pulse rate slower than in youth. These changes are brought about by stimulation of the accelerator and inhibi- tory nerves regulating the heart. Exercise increases the rate of the pulse. Even a slight change in position will increase or decrease it. For instance, the pulse when standing may be 80; when sitting 70, and when lying down 66. Heavy muscular work may increase the rate to 150 or 160. If the exercise has been light the pulse may return to normal in a few seconds; if strenuous, long continued and exhausting, it will probably be an hour or more before the rate subsides to normal. The pulse is slower during sleep and repose. An elevation in temperature causes a rapid increase in the pulse, the rate usually increasing about 10 beats per minute to one degree of elevation in temperature. The temperature and heart-rate rise and fall together, for the rate depends to a large extent upon the temperature at which the heart is working. (In typhoid fever, however, the pulse is low in proportion to the tem- perature.) The increase in rate is due to the direct influence of the heat upon the heart itself. Heat is one of the best heart stimulants and for this reason it is used both externally and in- ternally when necessary to stimulate a flagging heart. "An in- crease in heart rate is as much a symptom of fever as is the rise of the temperature, while the pulse-rate in fever is of even great- er value for prognosis than is the temperature. No matter how high the temperature, one does not worry so long as the pulse is fairly low; but let the heart rate rise to 140 or over, and the outlook becomes at once more serious." Some drugs, such as caffein and atropin, stimulate the heart and increase its rate, while others, such as aconite and digitalis, slow the rate. The pulse rate is also increased in all the acute diseases accom- panied by a rise in temperature; in diseases of the heart, in gas- tric disturbances, in shock and collapse, in exophthalmic goiter (in which there is an over-secretion of the thyroid gland which causes an over-stimulation of the nervous system and the heart), and also in many other diseases. When the heart beat is very rapid the condition is called tachycardia (rapid heart). The pulse is said to be "frequent" when it runs from 100 to 120; rapid, from 120 to 160. When it is above 160 or 170 it is very diffi- THE CARDINAL SYMPTOMS 169 cult to count and is described as "running," and the heart is said to be "running away." When the rate of the pulse is abnormally slow or infrequent the condition is called bradycardia (slow heart). A slow pulse usually occurs in exhaustion after severe exercise and in con- valescence following acute diseases, in toxemia—auto-intoxica- tion, uremia, and jaundice (bile in the blood poisons and weakens the muscles of the heart) ; in some cases of hysteria and melan- cholia; in accidents such as a fracture of the skull causing pres- sure on the base of the brain; in irritation or pressure on the vagus nerve which slows the pulse rate; in increased intracranial pressure, as in apoplexy and meningitis, and as a result of the action of drugs, such as opium, which depresses the nervous sys- tem, and digitalis, which stimulates the vagus nerve and there- fore slows the heart beat. All these factors—the influence of the emotions, of exercise, sleep or rest, of exertion and strain (either mental or physical), of digestion or interference with digestion, of exposure to cold or heat (air, water or clothing), of the body temperature, of the blood-pressure and of drugs, etc., on the action of the heart— must be remembered both when taking the pulse and when car- ing for patients suffering either from a diseased heart or from a disease, such as typhoid or pneumonia, in which the heart is being poisoned and weakened by the toxins of the bacteria and is already under a terrific strain so that any added work will increase the strain, possibly beyond endurance so that death may ensue. V. The Rhythm of the Pulse.—The beats of a normal pulse are almost equal in force and are separated by intervals of almost equal length. In disease the pulse may be irregular in force or Fig. 22.—Sphygmographic Tracing of an Irregular Pulse. (From Kel- logg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Publishers.) rhythm or, which is more common, in both. Irregularity in force means that the beats are not all of equal strength. Some will be strong while others are weak and feeble or scarcely felt at all. Irregularity in force may be temporary, due to over-exertion or to poisoning from the excess use of tobacco, tea or coffee, etc. It is a very serious symptom when occurring in disease of the heart, such as disease of the myocardium or of the aortic or mitral 170 THE PRINCIPLES AND PRACTICE OF NURSING valves, and in diseases of the blood vessels with loss of elasticity or sclerosis. Irregularity in rhythm means that the intervals between the beats are not all of equal length and the beats do not follow in rhythmical succession. The pulse may be intermittent, that is, at regular (every 2, 3 or 4 beats, etc.) or at irregular intervals, a beat is missed. The beat may only seem to be lacking because the heart-beat and the pulse wave are too feeble to be felt by the finger. These beats will be shown by the sphygmograph or 1/frflA m (0iiMMMMMj Fig. 23.—Sphygmographic Tracing of Irregular Pulse of a Tobacco User (Waller). (From Kellogg's "Rational Hydrotherapy," Modern Medi- cine Publishing Co., Publishers.) may be detected by listening directly to the heart-beats. In- elastic arterial walls easily obliterate feeble heart-beats, or dis- ease of an artery, such as an aneurysm, or external pressure from a tumor, or enlarged organ, or a fractured bone, etc., can prevent the beats from coming through. An intermittent pulse is not al- ways serious, as it is quite common in middle age and in the elderly, also in young children, or it may be due to nervousness, indigestion or the excessive use of tea or coffee. It may, however, be due to diseases of the heart. Sometimes the beats come "in twos" or "in threes," and the pulse is called a "bigeminal" or a "trigeminal" pulse. Sometimes, in diseases of the heart, the pulse Fig. 24.—Sphygmographic TRAaNG of an Intermittent Pulse. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Publishers.) is very irregular, some beats following each other in rapid suc- cession, while others follow slowly with long intervals between. These long pauses may be filled in by feeble beats which cannot be felt by the fingers. When the pulse is intermittent or irregu- lar in rhythm alone the condition is not so serious as when it is irregular in force. When irregular both in force and rhythm the condition is very serious, as it indicates that the heart is failing. Sometimes the pulse is so irregular that the condition is called "delirium of the heart." Irregularities in the pulse are spoken of as arrhythmias. CHAPTER XV THE CARDINAL SYMPTOMS (Continued) RESPIRATION Its Purpose and Vital Importance.—Respiration is the ex- change of gases between an organism and its environment, that is, the absorption of oxygen and the elimination of carbon di- oxid. It is one of the characteristics common to all living things in one form or another, for it is absolutely essential for the chem- ical changes of metabolism upon which life depends. Food is also essential but is of no use unless it can be combined in the tissues with oxygen, for only in this way can the combustion or burn- ing of the food take place with the production of heat and the power to do work, both of which are essential to life. The body can survive for a considerable time without food (except that from its own tissues) but not even for a few moments without oxygen. Oxygen and food are required by each and every cell in the body in order to maintain its life and its function, and they must not only be carried to the little cells, but must actually be ab- sorbed by the cells as the chemical processes of metabolism take place within the cells. Carbon dioxid is one of the universal waste products, resulting from these chemical processes, so that it is equally important that the body be provided with a system which will not only supply the tissues with oxygen but will also rid them of carbon dioxid, otherwise each cell would suffocate or smother to death. When we speak of a person "strangling" or "smothering to death" we really mean that their cells are smothering. The greater the activity of the cell, the more oxy- gen will be required and the greater will be the amount of car- bon dioxid to be eliminated. Provision for this exchange of gases is made in man by the respiratory and the circulatory systems. By means of the res- piratory system oxygen is absorbed into the blood and carbon dioxid is eliminated from the body. (Excess heat and water are also eliminated by means of this system.) By means of the circulatory system the oxygen absorbed in the lungs is conveyed to the tissues and carbon dioxid is conveyed from the tissues to the lungs to be eliminated. Both the respiratory and the cir- culatory systems are merely a means to an end, the end being the absorption of the oxygen by the cells, together with the chemical processes which follow and the freeing of the cells of the carbon 171 172 THE PRINCIPLES AND PRACTICE OF NURSING dioxid. Because the cells are so remote from the supply of oxygen there must not only be a means of transporting the gases but respiration, or the exchange of gases, must take place at both ends—between the blood and the air in the lungs, and be- tween the blood and the tissue cells. The former is called ex- ternal or pulmonary respiration, and the latter internal or tissue respiration. In order to understand external and internal respiration and the conditions which may interfere with them, it is necessary to understand the mechanism by means of which they are accom- plished. This understanding may be attained by a study of the anat- omy and physiology of the respiratory system as given in the textbook on that subject supplied to students. By this study it will be seen that anything which interferes with the inlet or outlet of air to and from the lungs, as in croup or asthma; or with the free movement of the respiratory muscles, as in convul- sions, causing a spasm of the muscles—the patient gets black in the face; or with the functionating area of lung tissue as in pneu- monia; or with the amount and quality of the air in the air sacs, or the amount and quality of the blood circulating freely through the capillaries in contact with them, as in heart diseases, etc.; or with the free circulation of blood through other organs of the body, will interfere with the exchange of gases in the lungs and with the supply of oxygen to the tissues, and therefore with the respirations. The Cause and Regulation of Respiration.—The factors which regulate and maintain the rhythmical movements of res- piration are (1) the respiratory center; (2) sensory fibers of the vagus nerve coming from the larynx and lungs; (3) the chemical composition of the blood. 1. The respiratory center is situated in the medulla and coin- cides in position with the sensory center of the vagus. It was called the "vital knot" by its discoverer, Flourens, because he found that when it was destroyed respirations ceased and death followed. This center sends out motor nerves which cause the contraction of the muscles of respiration. It is essentially auto- matic, that is, it sends out impulses to the muscles independent of any impulses sent to it, but is, however, very sensitive to sensory stimuli from all parts of the body. Sensory fibers travel to it through the vagus from the lungs and larynx. Sensory fibers also travel to it from the cerebrum so that stimulation of any sensory nerves in the body, through the cerebrum, may stim- ulate the respiratory center reflexly and so affect the rate and character of the breathing. For instance, a dash of cold water on the skin, the emotions, pain, and sensations or messages car- ried by the nerves of sight and hearing may make the breathing quicker and stronger, or may make it slower and more feeble, or cause it to cease altogether. The facts that nerves travel from the cerebrum to the respiratory center and that the muscles of THE CARDINAL SYMPTOMS 173 respiration are voluntary give one a limited control over the act of breathing (used in singing or speaking, etc.) but under normal conditions the whole apparatus works rhythmically and is purely involuntary. The effort to "hold the breath" is soon limited by exhaustion and by the accumulation of carbon dioxid and the lack of oxygen which it causes. It is thought by many physiologists that the respiratory cen- ter consists of two centers—an inspiratory and an expiratory center, but that in normal, quiet breathing the inspiratory center alone plays an active part. 2. The Sensory Fibers of the Vagus from the Lungs and Larynx.—The sensations or impulses from the lung itself which travel to the respiratory center stimulate it and regulate the rhythm of the respirations—the center starts the respirations, but the messages from the lungs regulate them. This explains why a patient (when the respiratory center is not paralyzed) may often be revived by artificial respirations, that is, by alter- nately expanding and filling the lungs with air and contracting them and expelling the air by rhythmical mechanical move- ments. It is thought that there are not only two centers—one which stimulates and one which inhibits respirations—but that there are separate nerves in the vagus from the lungs—nerves which check inspiration when the lungs are expanded to a certain de- gree and other nerves which stimulate inspiration when the lungs have returned to their normal size, in this way making the move- ments rhythmical. In normal, quiet breathing, it is thought, however, that the inspiratory center and the nerves which stimu- late it only play an active part, while in forced or difficult res- pirations other factors are brought into action. Stimulation of sensory nerves in the nose, pharynx, larynx, or bronchial tubes, for instance, by injurious gases, dust and other foreign bodies, will check respirations and cause the glottis and bronchial tubes to close in order to protect the lungs. 3. The Chemical Composition of the Blood.—The stimulus required to stimulate the respiratory center and make it auto- matic is the presence of carbonic acid (carbon dioxid in water) in the blood. The activity of the respiratory center is increased in rate and force in proportion to the increase or decrease of carbonic acid. If the blood contains a large percentage of oxy- gen and a small amount of carbon dioxid, the respirations will be feeble and may stop altogether. Carbon dioxid, then, is the normal stimulus to the respiratory center. The respiratory center starts the respirations, the nervous stimulus through the vagus from the lungs maintains the rhythm and the chemical stimulus (carbon dioxid in the blood) regu- lates the rate and depth of the respirations. Normal Respirations or Breathing.—Normal breathing con- sists in a rhythmical rising and falling of the chest wall and of the walls of the abdomen occurring in an adult about 18 times per 174 THE PRINCIPLES AND PRACTICE OF NURSING minute and carried on unconsciously, without effort, sound, or pain. The Method of "Taking" the Respirations.—As in taking the pulse, the patient should be at rest both mentally and physi- cally. Allow the effect of exertion and all mental excitement or nervousness to subside, for these will increase the rate and alter the character of the breathing. Even the consciousness of being watched will cause an involuntary change in the rate and rhythm, so the respirations should be counted without the patient's knowledge. After counting the pulse, with the fingers still on the wrist as though still engaged in counting the pulse, watch the rise and fall of the chest or upper abdomen, or if it causes no discomfort to the patient, when counting the pulse allow the pa- tient's arm to rest lightly on the lower thorax so that after counting the pulse and without watching the patient you can feel the chest and abdomen rising and falling. In this way you can count the respirations without the patient's knowledge. Some- times you may count from hearing them distinctly. Count for one minute. There are certain characteristics to be noted, how- ever, which can only be observed by watching the movements of the chest and abdomen. What to Observe when Taking the Respirations.—A nurse must observe the rate and character of the respirations, the movements and expansion of the chest and abdomen, the color of the patient, and the position he may instinctively assume. I. The Rate of the Respirations.—The average rate for a healthy adult is from 14 to 18 per minute, but it is greater in childhood (20 to 25) and in infancy (30 to 40). In health there is a uniform relation between the frequency of the pulse and of the respirations in the proportion of one respiration to four or five pulse beats. In health the respirations increase in rate and force under the same conditions as the heart to meet the needs of the body, but in disease this relation may cease. The respira- tions are usually increased with the pulse, but not always in equal proportions. In diseases of the lungs and air-passages the respirations may increase in much greater proportion than the pulse, while in other diseases (and this is more common) the pulse increases in greater proportion than the respirations. Conditions which Cause an Increase in the Rate or Depth, or both, in the Respirations:— 1. Conditions which directly or indirectly (messages which travel to and from centers in the cerebrum to the respiratory center) stimulate the respiratory center. The emotions have a marked effect on the respirations. Nerv- ousness or excitement may increase the rate to 60 per minute, but the breathing will be full, easy and painless. In other cases nervousness may slow the respirations—a long, sighing breath occurring every minute or so is characteristic of certain neurotic conditions. Sighing is a modified form of breathing, usually indicative of grief; the "heaving chest" may indicate grief or THE CARDINAL SYMPTOMS 175 anger; "gasping," surprise or terror. A cold bath or a "dash of cold water," by stimulating nerve endings in the skin and indi- rectly (or reflexly) stimulating the respiratory center will first make one gasp, then the breathing becomes fuller and deeper. Heat, a hot water bath or steam inhalations, will in the same way increase the rate and ease of the respirations, but makes them more shallow. These treatments are therefore used to re- lieve croup and asthma. Slapping the surface of the body, a hot bath with or without mustard, are methods used to stimulate the respirations in new-born babies. They stimulate the nerve end- ings in the skin and reflexly the respiratory center. Pain in any part of the body frequently causes increased respirations—the impulses from the irritated nerve endings are first carried to the cerebrum, then to the respiratory center. This may be seen in pleurisy, pneumonia, peritonitis, or in any condition causing severe pain. Sometimes, however, pain slows the respirations. Toxins, present in the acute infections and in uremic poisoning, etc., directly stimulate the respiratory center and increase the rate of the respirations. The heat, or elevated temperature, present in the acute infections, also increases the rate because the heat stimulates the heat-regulating centers which set about getting rid of the excess heat, one means being by increased res- pirations. Cerebral affections which stimulate the respiratory center cause an increased rate in respirations. Certain drugs, such as atropin, which directly stimulate the respiratory center, increase the rate. 2. Conditions affecting the circulation which cause an in- creased rate.—Pneumonia and other inflammatory diseases of the lungs which cause congestion and consolidation of the lung, thereby limiting its functionating area and also interfering with the circulation, will greatly interfere with the exchange of gases and cause an increased rate to make up the lack of oxygen; the accumulated carbon dioxid also causes an increased rate. Heart diseases, nephritis, and other conditions which interfere with the circulation interfere with both internal and external respiration. The respirations are increased in order to meet the demand for oxygen and to get rid of the carbon dioxid. Hemorrhage, in which the volume of blood is lessened so that there are not enough red cells and hemoglobin to carry the oxygen so that the tissue cells are strangling to death; shock, in which a large vol- ume of blood is congested in the large abdominal veins instead of circulating through the lungs will have the same effect as an actual loss of blood—the respirations will be rapid and sighing. 3. Conditions affecting the composition of the blood which cause an increased rate.—Conditions which increase the amount of carbonic acid or other acids; conditions which greatly reduce the amount of oxygen or which increase the demand for oxygen will cause an increased rate in the respirations in order to get rid of the carbon dioxid and supply the oxygen. Increased car- 176 THE PRINCIPLES AND PRACTICE OF NURSING bonic acid directly stimulates the respiratory center; other acids, such as are present in acidosis, likewise stimulate the respiratory center. Increased metabolism in the body from any cause de- mands more oxygen and causes an increase in carbon dioxid; toxins in the blood increase the rate not only because they di- rectly stimulate the respiratory center but because they increase tissue destruction or metabolism. Exercise and all forms of ex- ertion or muscular work demand more oxygen and cause an in- crease in carbon dioxid; exercise and muscular work also in- crease the amount of other waste products, such as lactic acid, and this, as well as the carbonic acid, directly stimulates the respiratory center. In anemia there is a reduction of red cells and of hemoglobin and so a great decrease in the oxygen carrying power of the blood; in poisoning from gases, such as carbon monoxid, there is a marked decrease in the supply of oxygen to the tissues because hemoglobin combines more readily with this gas than with oxygen and so becomes saturated with it and is unable to carry oxygen: The small amount carried in the plasma is all that the tissues receive. Respiration must be more rapid in the effort to supply the deficiency. 4. Changes in the atmospheric pressure which increase the rate.—In high altitudes such as are encountered in balloon ascen- sions or in high mountains, the pressure of oxygen in the atmos- phere is very low so that there is not enough absorbed into the blood. The result is "mountain sickness," characterized by great weakness, and "air-hunger" because the cells have not enough oxygen to perform their work and are strangling to death. The normal amount of oxygen in the air is 20 per cent, and this is ample to meet the body needs and allows a sufficient margin of safety. When the amount is reduced to 10 per cent, this margin of safety is removed. In high altitudes there is only a slight margin of safety. Lack of oxygen, besides interfering with the life processes of the cells, produces poisonous substances in the blood—products of incomplete oxidation—which directly affect the brain. When the pressure of oxygen is higher than normal the result may be dangerous because injurious to the body tissues. Ani- mals die of convulsions when exposed to a high pressure of oxy- gen. The results of too much oxygen are seen in Caisson disease. Great care must therefore be taken when administering oxygen to a patient, to supply a lack of oxygen, to regulate the pres- sure. The gas first passes through a flask of water in which you can see the bubbles of gas and so can estimate and regulate the pressure of the oxygen administered to the patient. 5. The Body Temperature.—A high body temperature, as stated previously, will increase the rate of respirations as a means of eliminating the excess heat. A high body temperature will also increase the metabolism in the body. It causes increased destruction of body tissue and emaciation. The hemoglobin gives up its oxygen more readily. Oxidation processes are also stimu- THE CARDINAL SYMPTOMS 177 lated, increasing a demand for oxygen and increasing the amount of carbon dioxid. A Low Body Temperature. —The oxyhemoglobin readily gives up its store of oxygen to the tissues only at body temperature. If the temperature is subnormal the oxyhemoglobin will not give up its oxygen readily and the tissues will not be able to carry on their functions. 6. Mechanical interferences with the breathing which cause an increased rate.—These also cause a change in the character of the respirations, in the action of the muscles, the movements of the chest and abdomen, and in the position of the patient. Ex- amples of mechanical interference are: — (a) Obstruction to the air passages from a foreign body or increased secretions as in croup or bronchitis; edema or swelling of the tissues around the glottis, a stricture of the glottis, or a spasmodic contraction of the muscles of the glottis in each case narrowing the passage; (b) Contraction of the muscles of the bronchial tubes as in asthma, narrowing the air passage; (c) Paralysis of the muscles on one side (hemiplegia) so that the lungs on that side cannot expand; (d) Fluid in the pleural cavity (as in pleurisy with effusion) or air in the pleural cavity will limit the motion on that side and increase the expansion of the other side; pleural adhesions, in old pleurisy or tuberculosis, which bind the lung down, will also prevent expansion and limit motion on the dis- eased side, (e) An enlarged liver or spleen will prevent the diaphragm on one side from contracting and so will prevent expansion of the chest on that side. Rigidity of the abdominal muscles as in peritonitis will prevent the descent of the dia- phragm. The presence of fluid in the abdomen (ascites), a tumor, dilated stomach or distention (gas in the intestines) will push the diaphragm upward so that it cannot descend and the work must be thrown upon the thoracic muscles; (f) Diseases of the lungs, such as pneumonia, tuberculosis and emphysema, which limit the functioning area for the exchange of gases: In pneumonia, the lower lobes may be consolidated so that air can- not enter or the lung expand: In tuberculosis, the apex of the lung will fail to expand and the normal lung will have to ex- pand more freely and do more work. In all the above cases where the function of a part of a lung, a whole lung, or both lungs is interfered with the respirations will be more rapid in order to supply sufficient oxygen. In health the abdominal breathing is most pronounced, while in forced or diffi- cult breathing the costal type is marked. In certain diseases there may be an exaggeration of one or the other. In the above cases where the normal descent of the diaphragm is prevented costal breathing will be more marked. Conditions which Cause a Decrease in the Rate.—Any con- dition which causes an increase in the intracranial pressure will depress the respiratory center so that the breathing will be slow or it may be irregular. The pressure may be due to a tumor or 178 THE PRINCIPLES AND PRACTICE OF NURSING to a cerebral hemorrhage, as in apoplexy, or to pressure from a bone in fracture of the skull, or it may be due to an increase in the cerebrospinal fluid, as in meningitis. In diabetic coma and uremic coma the respirations are slow or irregular and stertorous, due to exhaustion and failure of the respiratory center. At first the poisonous products of metabol- ism in the blood stimulate the respiratory center, making the respirations more rapid, but when the stage of coma develops (produced by the poisonous substances) all the centers of the brain, including the respiratory center, are depressed and ex- hausted. Toxins and drugs such as atropin and strychnin, etc., which stimulate, will, through exhaustion, finally depress the respiratory and other nerve centers. Certain drugs, particularly opium and the preparations of opium, depress the respiratory center and slow the respirations. In poisoning from opium the respirations may be depressed to a dangerous degree. In pneumonia when opium is given to relieve delirium and to induce rest and sleep, the breathing must be watched very closely because opium depresses the respiratory center, which is already becoming exhausted from the effects of the toxins and high temperature. If the respirations are decreased to below 8 or increased to above 40 the outlook is very serious. II. The Character of the Respirations.—Respirations are described as "deep" or "shallow," depending upon whether the volume of air inspired and expired is greater or less than normal. "Rapid" respirations are usually "shallow." Whatever interferes with the proper expansion of the chest, or with the inlet or outlet of air, or with the functioning area of the lungs, will decrease the volume of air inspired or expired. For instance, in pain due to pleurisy the patient will take quick, shallow breaths in order to limit the expansion of the lungs so as to prevent the irritated pleural membranes from rubbing together. The position of the patient is also an important diagnostic factor: He will lie on the affected side so that the pressure of the bed will prevent expan- sion on that side and also so that the other unaffected side will have unlimited room for expansion. In pneumonia, tubercu- losis and other diseases of the lungs, the breathing will be shal- low and the patient usually lies on the affected side to allow the other lung free expansion. In pain due to peritonitis, when every movement causes more pain and irritation, the patient instinc- tively holds the diaphragm and the muscles of the abdomen rigid and takes quick, shallow respirations in order to protect and prevent irritation of the inflamed tissues within. The respi- rations are usually shallow in conditions of marked prostration in which all the vital centers are depressed and exhausted. "Deep" respirations occur usually in the same conditions which give rise to slow breathing so that the respirations are "slow" and "deep" in all conditions which give rise to increased intra- cranial pressure, and also in diabetic and uremic coma. THE CARDINAL SYMPTOMS 179 Dyspnea means difficult breathing—dys comes from a Greek prefix meaning bad or difficult and pnoz which means breathing. This condition resembles the "breathlessness" or being "out of breath" which we have all experienced from climbing several flights of stairs rapidly or from running a distance to "catch a car," but instead of being temporary and of short duration it continues hour after hour and day after day. The respirations are almost always rapid and deeper and are usually accompanied by pain. Every breath is quick and la- bored, performed with great difficulty and only after a hard struggle so that the patient is exhausted with the prolonged effort. Dyspnea is caused by an increase of carbon dioxid and a de- crease of oxygen in the blood resulting from incomplete meta- bolism—as stated previously, carbonic acid and the acids re- sulting from prolonged exercise, or which occur in acidosis, pow- erfully stimulate the respiratory center and increase the rate and depth of the respirations. It occurs therefore in all those conditions already mentioned which cause an increase in the carbon dioxid, or a decrease and a demand for oxygen, and in diabetic acidosis—the "air-hunger" of diabetes. The symptoms are rapid, labored breathing, with a distinct, audible sound; the lips are usually blue or a dusky color; the face has a distressed, anxious expression; the eyes are promi- nent; unusual muscles are forced into action; the nostrils dilate; the upper part of the chest is greatly expanded by the action of muscles at the sides of the throat (the sternocleidomastoids) at- tached to the sternum, clavicle and mastoid bones; the dia- phragm contracts with force and the abdominal walls protrude, so that each breath is drawn with "heavings" of the chest and abdomen. Frequently the dyspnea is so severe that the patient can only breathe when sitting up and so is obliged to sit up night and day. This condition is called orthopnea. Both the dyspnea and position are extremely exhausting; the patients are most pathetic and require the very best nursing care. The pa- tient usually leans forward (to be free of the pressure of the bed) supporting the weight of his shoulders with his hands or arms resting on the bed or table, because in this position all the accessory muscles of respiration can work to better advan- tage. When the dyspnea is prolonged and severe and the patient weak and exhausted, the action of the respiratory muscles be- comes more pronounced and the breathing is frequently irregular and gasping. The forceful contraction of the diaphragm draws the sternum and ribs downward and inward, seeming to "suck" them in so that a marked depression and groove is formed at each inspiration in the front and lower border of the chest. Nor- mally this is prevented by the pull of other muscles attached to the sternum and ribs. Sometimes also the action of the sternocleidomastoid and the trapezius muscles becomes exagger- ated so that at each inspiration the upper part of the chest is 180 THE PRINCIPLES AND PRACTICE OF NURSING elevated, the head is drawn back, the chin being thrown quickly upward. During expiration the head falls forward and the chin slowly falls so that each respiration is accompanied by a nodding or rocking movement of the head. These symptoms are of very grave significance and indicate the near approach of death. Dyspnea may affect inspiration or expiration or the whole act may be a struggle. Inspiratory dyspnea is usually due to spasm or to obstruction in the air-passages, as in croup, edema of the glottis, diphtheria, and whooping cough. It gives rise to a very characteristic sound —high-pitched, crowing, harsh, and grating (stridulent breath- ing) and the whoop in whooping cough. In coma, apoplexy, or profound unconsciousness from any cause, each inspiration may be accompanied by a loud, snoring sound and the cheeks puff out at each breath. This is called stertorous breathing and is due to the vibrations of the relaxed soft palate. Expiratory dyspnea occurs in asthma and in chronic bron- chitis. In asthma the air seems to enter rather easily but a spasmodic contraction of the bronchial muscles narrows the tubes so that expiration is painfully prolonged and "wheezing." In bronchitis the tubes are partially closed and contain secretions so that the sound is "wheezing" and the rattle of bubbles (air in fluid) may be heard all over. In diseases of the respir- atory tract, near approaching death, when the fluid in the trachea and bronchi is abundant, this rattling, bubbling sound may be heard at a distance, and is spoken of as the "death- rattle." In pneumonia the breathing is shallow, difficult and painful, and each expiration is made with a characteristic "grunt- ing" sound of discomfort. It is really a little moan from pain. "Sighing" and "yawning" respirations occur when the cells are smothering for want of oxygen, as in severe hemorrhage, in which sighing, shallow respirations are an important symptom. When the demand is very great the condition is called "air- hunger," in which the patient is very restless, gasping and fight- ing for air. The air-hunger in diabetic coma is due to the exhaustion of the respiratory center. The respirations are full and deep. Dyspnea is usually accompanied by cyanosis, a blue or dusky hue to the skin due to the fact that the blood flowing through the vessels of the skin is venous in character instead of arterial. This is easily understood when it is remembered that the dysp- nea is due to the increase in»carbon dioxid and the decrease in oxygen, the presence of which with hemoglobin gives the arterial blood its red color. This dusky hue may be noticed first about the lips and in severe cases in the extremities under the nails, and finally over the whole body. Cheyne-Stokes Respirations.—Dyspnea means difficult breathing in which the respirations are usually rapid, deep and noisy. Apnea means absence of or a complete cessation of breathing. Dyspnea occurs when there is a marked increase THE CARDINAL SYMPTOMS 181 of carbon dioxid and a decrease of oxygen in the blood. Apnea occurs when there is an increase of oxygen in the blood and a decrease of carbon dioxid and therefore of the normal stimulus to the respiratory center. Cheyne-Stokes respirations (called after the two men who first described them) consist of periods of dyspnea preceded and followed by periods of apnea and occurring in a rhythmical cycle, each paroxysm lasting from thirty to sixty seconds. The period of dyspnea begins with short, shallow respirations, almost inperceptible, but each res- piration increases in rate, depth and sound until a maximum of dyspnea is reached, when they gradually decrease in rate, depth and sound, until they finally cease altogether and the apneic period begins. (In children usually there is no gradual decline but the maximum of dyspnea ends with a long-drawn sigh fol- lowed by a period of apnea.) It may last from one to ten sec- Fig. 25.—Stethograph Tracing of Cheyne-Stokes Respirations in a Man. The time is marked in seconds. (From Kimber's Anatomy and Physiology, Macmillan Co.) onds when the whole cycle will begin again. During the period of apnea the patient may drop off to sleep for a few seconds, but during the period of dyspnea even though asleep, he is apt to be restless. While Cheyne-Stokes respirations may occur in healthy chil- dren and in healthy adults when asleep, particularly when lying flat on the back, in disease it is always a very grave symptom. Patients have recovered in whom this grave symptom has been marked, but in acute illness Cheyne-Stokes respirations are usually regarded as a sign of approaching death. They occur in conditions in which the respiratory center is almost exhausted and too weak to be stimulated by the usual amount of carbon dioxid in the blood. During the period of apnea an abnormal amount of carbon dioxid is allowed to accumulate, sufficient to stimulate the failing center; during the periods of dyspnea the respirations are so rapid and deep a large amount of oxygen is accumulated and the respiratory center rests, breathing ceases, until again stimulated by a sufficient amount of carbon dioxid. This form of breathing is most common in severe heart dis- eases, uremia and in cerebral diseases with increased intracranial 182 THE PRINCIPLES AND PRACTICE OF NURSING pressure. It occurs in tuberculous meningitis either in its typi- cal or in a modified form. Too much emphasis cannot be placed upon the careful obser- vation of the respirations—the rate and character, the position of the patient, the movements and expansion of the chest and abdomen. No one but a nurse, not even the doctor, is in a posi- tion to make these observations to the best advantage. A nurse may observe the patient during night and day, asleep or awake, and during her many duties in the care of the patient, who is apt to be more natural, less conscious, and more "off her guard" with the nurse than during the often unexpected, or anxiously expected and often hurried visit of the doctor. The temperature, pulse, and respirations are the three cardinal or "vital symptoms." They each indicate the condition of vital organs in the body and are the chief means of finding out the patient's general condition. To read these important signs ac- curately requires knowledge, study, and experience, with close and accurate observation. Taking note of these symptoms may be a means of saving the patient's life, whereas ignorance, thoughtlessness, or neglect may cause the loss of valuable time in treating the patient, which may mean loss of life which might otherwise have been saved. THE TEMPERATURE, PULSE AND RESPIRATIONS DURING INFANCY The degree of body temperature during infancy and childhood is of tremendous importance as an indication of health or dis- ease and is an important guide in the treatment and nursing care. How Infants Differ from Adults.—1. The normal rectal temperature varies from 98° to 99° F. It varies much more in infants than in adults because the body temperature is much more readily affected both by conditions within and without the body. An infant in this respect more nearly approaches a cold- blooded animal which has about the same temperature as the medium with which it is surrounded. This is because the heat- regulating centers in the brain and the whole nervous mechanism which maintains a proper balance between the production and elimination of heat (the normal body temperature) are not nearly so stable as in an adult. Heat elimination does not keep pace so readily with heat production and heat is often not so readily produced in the body to make up for that lost. 2. Infants must sleep a great deal and during sleep less heat is produced. For this reason particular care must be taken to see that they are kept warm while asleep. 3. Again, infants, particularly young infants, are inactive, so do not produce so much heat in this way. They exercise by crying, waving their arms and legs about, grasping at things and trying to get up, etc. The child's clothing and bedclothes, etc., must allow for sufficient exercise as it is not only a means of THE CARDINAL SYMPTOMS 183 producing heat, but of developing muscular strength and growth. Their position should be changed and they should be taken up several times during the day. Just as inactivity may lower the temperature, overactivity, as in convulsions in an infant or overexertion in the boisterous play of a young child may cause a rise in temperature. 4. Infants also lose relatively more heat by radiation than adults because their skin surface in proportion to their size is relatively greater than in an adult. More blood is thus in con- tact with the surrounding medium. For this (and the reasons mentioned above) an overheated room or excessive clothing may cause fever in an infant, and exposure to cold or chilling may cause the temperature to fall below normal, particularly in very young or very weak infants. A subnormal temperature in infants is much more important and serious than in adults. Special care must be taken to avoid exposure to drafts or to cold while feeding, bathing or giving treatments to infants. They must be kept warmly wrapped in a soft warm blanket, and bathed, etc., near the radiator or an open fireplace if available. The head and chest must be protected because infants are very susceptible to respiratory diseases; the feet must be warm be- cause cold feet cause congestion in the head and chest which predisposes to respiratory diseases. Cold feet also cause colic. The abdomen must also be well protected to avoid chilling the intestines, and causing colic and congestion of other abdominal organs. Abdominal bands are applied for this purpose as well as for other reasons. When the temperature is subnormal, as it is apt to be in premature babies, or poorly nourished and very weak infants, external heat must be applied in order to raise the temperature to normal in order to maintain life. These in- fants must on no account be removed from the source of heat or exposed to cold in any way. In summer, on the other hand, excess clothing should be avoided. 5. The above reasons also explain why children react so readily and why particular care must be taken in such treat- ments as hot baths for stimulation or convulsions, etc., and cold sponge baths or cold rectal irrigations for the reduction of tem- perature, etc. 6. Conditions within the body also affect an infant much more readily than an adult. Diarrhea may quickly lower the tem- perature by abstracting heat from the body. A subnormal tem- perature is to be watched for and guarded against. Lack of fluid in the body, a slight digestive disturbance or a mild infec- tion which would not affect (or only slightly so) the temperature of an adult may cause a high fever in an infant. Infants stand a high temperature better than adults. Fever lasting a few hours does not cause much anxiety, but if continued, it indicates that something is wrong, and that the condition may be serious. A rise in temperature, however slight, if continued, should never be ignored. 184 THE PRINCIPLES AND PRACTICE OF NURSING All the above factors emphasize the importance of the care of the skin, the protection from cold, the proper diet, amount of clothing, exercise, fresh air and sunlight and explain why per- sonal hygiene is one of the greatest factors in the nursing care of infants and children. Method of Taking the Temperature of an Infant.—The temperature of an infant or young child should always be taken by rectum as it is the most reliable. There should be a separate thermometer for each infant. The thermometer should be well lubricated before insertion. If an infant struggles while taking the temperature turn it on its face or hold it face downward on your knee. With the child in this position, after insertion point the thermometer downward toward the umbilicus so as to follow the curve of the rectum. Never leave a young child alone with a thermometer inserted. The pulse and respirations during infancy are not nearly so significant as the temperature. As a rule no record is kept on the chart during the first year of infancy. Infants are restless, the tension of the pulse is lower than in adults, and the rate is difficult to count accurately. Nurses, however, should carefully note the character of the pulse and respirations in all diseases (such as those of the respiratory tract, the acute infections or congenital heart disease) likely to affect the pulse or respira- tions. The rate of the pulse and respiration both vary with age. In both, also, very slight causes produce wide variations due to the unstable nervous system. At birth the pulse varies from 120 to 150 per minute; at the end of the first year from 120 to 110; in the third or fourth year it falls to 100 and continues to fall gradually until the age of puberty, when it is the same as the adult pulse. At birth the respirations vary from 30 to 60; in the first year from 25 to 30; in the fifth year from 22 to 25, and in the four- teenth year are about 20. CHAPTER XVI ELEMENTARY NURSING IN A MEDICAL WARD On the medical ward there are infinite possibilities and constant demands for the exercise of all the patience, sympathy, knowledge and skill which a nurse may possess or acquire. For in the treat- ment of medical diseases—pneumonia, typhoid, rheumatism and heart disease, etc.—the recovery of the patient depends more upon good nursing than upon any other factor. To provide the patient with fresh air, proper food, rest, sleep and comfort will, alone, go far toward helping Nature to overcome the disease, and these the youngest nurse on the ward may share in providing. No quick and miraculous treatment like an operation on a sur- gical ward exists which quickly brings the patient out of danger and sends him on the road to recovery. Complete recovery is usually a long, slow process, so that the patient is much more apt to suffer from the long unnatural confinement in bed and the departure from a normal active life. The treatments pre- scribed by the doctor—the application of mustard pastes, a hot- water bag, fomentations, an ice-cap, poultices, baths, packs, and sponges, etc.—are all carried out by the nurse and their effect on the patient will to a large extent depend upon her knowledge and skill in giving them. In nursing in medical diseases a nurse must be keenly alert to observe every symptom and to note the effect of each treatment, for the doctor is not there to note its effect, and treatments will be continued or altered according to their effect on the patient. Whatever appeals in nursing,—whether it be the ideal of serv- ice, or an interest in science, in people, and in disease, or the fas- cination of a busy, varied, active life, or the desire to become a skilled, well-informed and well-equipped nurse—may all be grati- fied in the care of patients on a medical ward. Probationers may serve and share in this valuable experience by caring for the convalescent patients and by assisting older nurses in the care of patients who are acutely ill. Among the treatments for which they may be responsible are the application of the following: a hot-water bag; baking a rheumatic limb; a hot foot-bath; fomentations; a hot flaxseed poultice; a mus- tard paste; an ice-cap and cold compresses. Before studying these treatments it will be necessary to have some idea of the conditions they are chiefly intended to relieve, so that we may understand the effects they are intended to pro- duce and the care with which they must be applied in order to get the best results. 185 186 THE PRINCIPLES AND PRACTICE OF NURSING Conditions and Purposes for which the Applications are Used:—1. To relieve pain due to irritated sensitive nerves.— Pain is a symptom which demands immediate relief. It is Na- ture's way of reporting an injury and insisting that the part will not be used until the condition or injury is relieved. Pain may be due to pressure on the nerves, or to direct injury to the nerves. It may be relieved by applications which remove the pressure, soothe the nerve endings, or actually deaden the sensation of pain. 2. To relax muscles, tendons, ligaments and fascia.—Some- times muscles, ligaments and tendons, become stiff, fatigued, cramped, and painfully contracted from strain, overwork, expos- ure to cold, or from the accumulation of waste products, toxins from bacteria, and other poisonous substances. They are then not only painful but are unable to function properly. For in- stance, a cramped heart muscle can no more pump the blood into the arteries properly than we can write freely or legibly with stiff, cramped, and painful fingers. Applications may be made to relax these tissues, relieve pain, and restore their function. 3. To cause the contraction of muscles.—Muscles of the inter- nal organs, such as the heart, blood vessels, intestines and blad- der, may lose their tone so that they become relaxed, unable to contract and to function properly. For instance, the relaxed intestines allow the accumulation of gas and fecal matter within them. This causes discomfort and pain and interferes not only with digestion but with the action of vital organs, the heart and lungs. The relaxed walls of the bladder cause retention of urine; the relaxed heart muscle beats very feebly so that the circula- tion of the whole body suffers. Applications may be made to stimulate and restore the tone and function of these muscles. 4. To relieve inflammation and congestion. What Inflammation is.—We are all familiar with an inflam- matory process in the form of cuts or bruises, styes or boils, burns or frost bites, toothache or earache, "sore throat," or the common "cold in the head." Many of us are, and all will become familiar with more deep seated and more serious inflammatory processes in the form of pneumonia or pleurisy, typhoid or tuber- culosis, nephritis or cystitis, appendicitis or peritonitis, pericar- ditis, rheumatism, poliomyelitis, and many others, each and all of which represent the local attempt made by the tissues in self- defense against an injury. Perhaps most of us, because of the discomfort involved or the results of an unsuccessful defense, have thought, and indeed have been taught to think of inflammation as a "morbid process"—an evil to be checked by every possible means. Whereas it is now recognized as "the immediate protective and defensive reaction to an injury"—a "purposeful and beneficial reaction." It is an effort on the part of Nature to destroy the injurious agent, to prevent further injury, and to remove the products of the struggle so that repair or reconstruction may take place. ELEMENTARY NURSING IN A MEDICAL WARD 187 It is interesting and wonderful to note how, in the course of ages, the body has inherited or acquired various means of defend- ing itself against injury until we find at each point some mechan- ical or chemical guard, and to note how inflammation takes its place, so to speak, in the second line of defense. Our first line of defense is made up of guards so familiar, so prompt and indig- nant, so automatic and perfect in their response to injury, that we sometimes think of the remedy as the disease, as in vomiting, and fail to appreciate the service rendered. Guards in the First Line of Defense.—The respiratory tract indignantly expels injurious substances by sneezing or coughing; the stomach by vomiting; the intestines by diarrhea; the eyes by tears and blinking. The pupils of the eyes contract to keep out light. The skeletal muscles contract, we shiver and shake to make heat when we are cold. The abdominal muscles con- tract, we bend over to ward off an expected blow on the abdo- men in order to protect the more vital organs. Many other examples of the instinctive contraction of muscles to expel injuri- ous substances or to ward off injury might be given. In addi- tion to these defenses, the impervious skin, enforced by hairs and nails, the cilia of various linings, the perspiration, gastric juice, bile, and other secretions all play their part in the first line of defense against injury. But in spite of this marvellous system of protection the body is still exposed to injury and the portals are constantly besieged by an army of bacteria ready to destroy the tissues should the first line of defense break down. Should this happen, let but a few cells be killed, the challenge will immediately be met by an inflammatory process, our second line of defense, or the local reaction of the tissues to injury. Causes of Inflammation.—This injury, or death of tissue cells, may be caused by various agents such as the following: I. Physical Agents. 1. Heat, electricity or the sun's rays causing burns of varying degree. 2. Cold, causing frostbites, freezing, or chilblains. II. Mechanical Agents. 1. Foreign bodies such as slivers, metal, bullets or needles which may be carried into the tissues. Sutures left in the tis- sues, if not absorbed, act as a foreign body. Gauze left in a wound as packing, dead tissue cells or dead bone act as foreign bodies. Food or secretions carried into the lungs act as foreign bodies, and may set up a foreign body pneumonia or a septic abscess. Pins, coins, seeds or pebbles, etc., may be carried into the respiratory or alimentary tracts. Children, sometimes, poke seeds, pebbles or other round objects into their nose or ears, where they remain and cause inflammation. 2. Friction as from the irritation of a collar or other clothing; restlessness in bed; two body surfaces in contact, together with 188 THE PRINCIPLES AND PRACTICE OF NURSING heat and moisture, as in fleshy people, or in improper bandaging; blisters, corns, or bunions from the friction of shoes. 3. Pressure as from the weight of the body on the bed which shuts off the circulation and causes bedsores (decubitus ulcers); a tight bandage, cast, or splint which interferes with the circu- lation. Any interference with the circulation to a part and any interruption of the nerve supply, either from pressure or injury to the spinal cord with resulting paralysis, may result in death of skin and tissue with ulcer formation. Pressure from direct violence or trauma may result in bruises, cuts, wounds, fractures, dislocations, sprains, or rupture of an organ, all of which are accompanied by inflammation. III. Chemical Agents. 1. Acids, as in an "acid mouth," causing sore gums and de- cayed teeth; acid urine or stools causing sore buttocks; hyper- acidity in the stomach. 2. Alkalies as in decomposing urine which liberates ammonia and causes sore buttocks; lime in the eyes or swallowed by mis- take causing burning and ulceration. 3. Disinfecting solutions, such as bichlorid of mercury, Dakin's solution and iodin, etc. 4. Counterirritants such as mustard and turpentine. 5. An exudate from a discharging ear or from a wound which may cause irritation, eczema, or ulceration of the skin. 6. Poison from plants or animals and toxic substances from bacteria or dead cells. IV. Bacteria. All pathogenic microorganisms and dead disintegrating cells produce toxins which act in the same way as chemical poisons. In diphtheria the bacteria do not penetrate beyond the throat but the toxins they produce are absorbed and may cause death; in pneumonia the bacteria are chiefly in the lungs, but the toxins produced by them and absorbed may so poison and weaken the heart that the patient dies, not from the injury to the lungs but from heart failure; after childbirth or after an abortion, should a portion of the placenta remain in the uterus, the patient may die from a general blood poisoning (sapremia) because the tis- sue, receiving no blood supply, will die, disintegrate, and form toxic products which will be absorbed into the blood stream. Many similar examples might be given. The following are the most important pathogenic bacteria: (1) Streptococcus hemolyticus " viridans " mucosus " erysipelatis associated with sort throat, tonsillitis, quinsy, otitis media, meningitis, brain abscess, wound infections, pneumonia, en- docarditis, septicemia. ELEMENTARY NURSING IN A MEDICAL WARD 189 The streptococcus grows in chains, most commonly on mucous membranes, and is apt to cause spreading infections. (2) Staphylococcus aureus albus " citreus associated with abscess formations—boils, furuncles, carbuncles, stitch abscess, pye- mia, impetigo, endocarditis, septicemia, osteomyelitis and infected wounds. The staphylococcus is a common inhabitant of the skin, enters through cracks or abrasions and, on account of its marked tend- ency to cling together in clusters, makes a concentrated attack on the tissues which is followed by an equally violent and con- centrated defense, resulting in liquefaction of the tissues or abscess formation. (3) Pneumococcus—associated with lobar pneumonia, some- times with meningitis, pleurisy, and peri- carditis. (4) Gonococcus—which attacks mucous membranes especially of the urethra, vagina, and conjunctiva, causing urethritis, vaginitis, salpingitis, arthritis, endocarditis, gonorrhea ophthal- mia, ophthalmia neonatorum, and vulvo- vaginitis in children. (5) Meningococcus which causes cerebro-spinal meningitis. Acute rheumatism followed by chorea, endocarditis, myocar- ditis, and pericarditis are also thought to be due to a micrococcal infection. These are the pyogenic micrococci and like all coccal infec- tions tend to repeated attacks, in contrast to infections or diseases caused by the bacilli, one attack of which tends to set up an immunity. (6) Diphtheria bacillus which produces an inflammatory diph- theritic membrane in the throat, while its soluble toxins produce widespread changes in the body. (7) Typhosus bacillus—the cause of typhoid fever, producing inflammatory lesions and ulcers in the lymphoid tissue (Peyer's patches) of the intestine. (8) Tubercle bacillus—the cause of tuberculous lesions in the larynx, lungs, pleura, intestines, peri- toneum, kidneys, lymph glands, adre- nal glands, bladder, meninges, skin, bones and joints. Symptoms of Inflammation.—The symptoms which indicate that a struggle is going on and that the tissues are defending themselves are heat, redness, swelling, pain, and local loss of function. 190 THE PRINCIPLES AND PRACTICE OF NURSING Nature of an Inflammatory Process or Nature's Method of Defense.—In order to recognize the steps in an inflammatory process as beneficial and protective, it is necessary to remember that the growth and function, the very existence of every little cell in the body, depend upon a constant supply of nourishing, life-giving blood, and an equally prompt and constant removal Fig. 26.—Portion of Inflamed Diaphragm to Show the Abundant Di- lated Blood-channels. (From MacCallum's "Textbook of Patholoev " W. B. Saunders Co., Publishers.) "inoiogy, of the waste products resulting from its activities. At some times this need is more urgent than at others. When cells are injured the need for a free circulation will be still greater because the damaged cells must have heat, food, and oxygen to rebuild and restore them, and because there will be more waste products to remove. Nature's first response to an injury, therefore, is to send an increased supply of blood to the injured cells. The'speed with which the response is made is seen in the immediate increase ELEMENTARY NURSING IN A MEDICAL WARD 191 in the warmth and redness of the part. The blood not only con- tains heat, food and oxygen to revive and rebuild the cells but it brings a large number of white blood cells which, if you re- member, have two very important functions to perform because of which they are often called the scavengers, and soldiers or phagocytes {phago, eat, and kytos, a cell) of the body. They Fig. 27.—Portion of a Normal Diaphragm to Show the Relatively Few Visible Blood-channels. (From MacCallum's "Textbook of Pathol- ogy," W. B. Saunders Co., Publishers.) travel out from the blood stream into the tissues and pick up dead cells, bacteria, and other foreign matter, and either devour and destroy them or carry them back through the lymph stream to the blood stream and to organs in the body where they can be destroyed and eliminated. If this reaction takes place in the tissues promptly all goes well and the tissues are soon restored. Nature, however, is usually very generous and frequently sends too much blood to the part, more than can promptly be carried 192 THE PRINCIPLES AND PRACTICE OF NURSING away or easily contained in the capillaries and small blood- vessels. The fluid then oozes out into the tissues, engorging all the lymph spaces between the cells, crowding the cells and caus- ing pressure on the sensitive nerve endings and so causing swell- ing and pain. Pain may also be due to direct injury to the nerves caused by the blow, etc. The injury, the swelling, and the pain Fig. 28.—Inflamed Omentum Showing Outwandered Leucocytes About a Small Vessel. (From MacCallum's "Textbook of Pathology," W. B. Saunders Co., Publishers.) together cause loss of function in the part. This loss of function will not be very serious if it merely involves a finger or even the temporary loss of the use of a hand, but if it involves a vital organ, such as the lungs, the supply of oxygen to the tissues will be interfered with; if it involves the heart not only the supply of oxygen, but the supply of food, the distribution of heat, and the removal of wastes; if the kidneys, the chief means of elim- inating waste products, and, if the skin (as in extensive burns) the chief means of eliminating heat will be interfered with. ELEMENTARY NURSING IN A MEDICAL WARD 193 Frequently, therefore, it is advisable to check this too gen- erous supply of blood by external applications. Again some- times it is advisable to stimulate the circulation by external applications so as not only to increase the inflow of blood, but to stimulate the outlet and the activity of the white blood cells in order to hasten the absorption and removal of fluid and waste products. This reabsorption of fluid and of waste products is called resolution. When this takes place, for instance, in the congested lung in pneumonia the lung tissue is said to be resolving. Again, so many cells may have been damaged and not only damaged but actually killed that the removal by the white blood cells and absorp- tion by the blood stream can- not take place fast enough unaided so that a slough (a mass of dead tissue in living tissue) is formed which must "slough away" before healing can take place. The more quickly it is separated and re- moved the more prompt the repair so that applications are sometimes applied to hasten it. Again, when bacteria are present applications may be used to check their activities or they may be used to stimulate the circulation and bring a large number of white blood cells to destroy the bac- teria. In the battle which follows tissue cells (the battle field), white blood cells (the soldiers), and bacteria (the enemy) will be killed. En- zymes from their dead, disintegrating bodies will digest or liquefy the whole mass of dead tissue, etc., forming a thick, greenish- yellow fluid called pus. The process by which the pus is formed is called suppuration, and when a circumscribed collection of pus is formed the result is called an abscess. Part of the pus will be absorbed and carried away by the lymph stream (resolution) and part of it may be discharged from the body. For instance, in a boil it may rupture the skin; in a lung abscess some of it will be coughed up. Applications may be applied to stimulate or check this process when advisable. This local reaction of the tissues to injury is called inflamma- Fig. 29.—1, Adhesions of Leucocytes to the Walls of a Capillary in an Inflamed Area; 2, Mode of Migration of a Polynuclear Leucocyte (Lavdowsky). (From Adami's "Principles of Pathol- ogy," Vol 1, Lea and Febiger, Publishers.) 194 THE PRINCIPLES AND PRACTICE OF NURSING tion. As we have seen it is always accompanied by more or less congestion. Congestion of blood in the blood vessels may occur without an inflammatory process. Interference in the circula- tion from any cause will result in congestion. The treatments studied in this chapter—the application of a hot-water bag, hot air (baking), a hot poultice, fomentations, a hot foot-bath, a mustard paste, an ice-cap or ice compresses—are all local applications applied either for a local or reflex effect. These treatments are all used on both the medical and surgical wards and in the treatment of a great variety of diseases. Before studying these treatments it is essential for nurses to understand the action of heat, the purposes for which the applications are made, and the symptoms which indicate that the desired results are being obtained. The applications of a hot-water bag and of hot air are each a means of applying dry heat. The applications of a hot poultice, fomentations, and a hot foot-bath are each a means of applying moist heat. The Action of Heat.—The effects produced in the application of heat to the body depend upon (1) the mode of application, that is, whether in the form of hot air, hot water, vapor, or elec- tric light, etc.; (2) the temperature; (3) the duration, whether short or prolonged; (4) the surface of the body exposed and whether the application is local or general; (5) the condition of the patient. The hot-water bag and baking are local applications applied chiefly for their local effect. The Local Effect of Heat on the Tissues:— Water 104° to 130° F.; or air 120° to 250° F. 1. On the Skin and Mucous Membranes.—A very high tem- perature (120° to 160° F.), which is hot enough to cause pain, will contract the numerous small involuntary muscles in the skin and small blood vessels and squeeze the blood out of the capil- laries and arterioles so that the part becomes pale, and bleeding, if present, is checked. At a more moderate degree of heat, how- ever, the involuntary muscles and elastic tissue in the skin become relaxed so that pressure normally exerted on the capil- laries and small blood vessels in the skin is removed and the vessels become relaxed. There is, therefore, more blood in the vessels of the skin so that there must be less blood in the blood vessels in the adjoining tissues under the skin supplied by the same blood vessels. In this way blood may.be drawn away from an inflamed, congested area beneath the skin, as in an infected finger or boil, so that pain is relieved by withdrawing pressure from sensitive nerve endings. The secretions of the skin are also in- creased so that it becomes moist and red. Prolonged applications soften and weaken the skin and lower its resistance. The veins, because they are more superficial and because their walls are thinner and less muscular than the arteries, become more dilated so that there is more venous blood in the part and the skin becomes dusky, instead of a bright red hue. ELEMENTARY NURSING IN A MEDICAL WARD 195 2. On the White Fibrous Tissue.—Tendons, ligaments, fascia, etc.—Heat softens, expands and relaxes, and so relieves pain and stiffness, and restores the function. This expansion of the body tissues by heat explains why a ring, shoe, or glove feels tighter when the hands or feet are hot as in summer. 3. On the Muscles.—Heat which can be tolerated in a foot-bath or a full bath (104° to 110° F.) relaxes the muscles and so relieves cramped, fa- tigued, painful muscles. A very high temperature applied locally for a brief period, for instance, a square of blanket wrung out of boiling water as in a fomentation will stimulate the contraction of involuntary muscles such as in the intestine, and so relieve pain due to gas. 4. On Bacteria.—Moderate heat favors the growth of bac- teria. 5. On the Blood.—Heat in- creases the number of leuco- cytes in the part. It there- fore promotes suppuration, aids and stimulates the absorption of inflammatory products (resolution), and relieves swell- ing and pain. 6. On Nutrition.—Heat is a vital stimulant. It stimulates all the activities of protoplasm and the cells, and so stimulates the formation of new tissue and growth. Note the effect of the sun on plants and fruit, and its effect on the skin in stimu- lating the pigment forming cells with the production of Fig. 30.—Diagram Showing the Ef- fect of Heat and Cold in Les- sening the Pain of Inflam- mation in the End of a Fin- ger. The small star indicates the point of irritation, e.g., a prick of a thorn. The line in the center of each figure is in- tended to represent the nerve going to the injured part; and at the side of each figure is an artery and vein connected by a capillary network. In a the cap- illary network around the seat of irritation is seen to be much congested; the nerve filaments are thus pressed upon, and pain is occasioned, b represents the condition of the finger after the application of cold to the arm or hand. In consequence of the contraction of the afferent arteries the finger becomes anemic; no pressure is exerted on the nervous filaments, and pain is alleviated, c represents the finger after it has been en- cased in a warm poultice; the capillary network at the surface of the finger is dilated, and the blood is thus drawn away from the seat of irritation, and the pain therefore relieved. (From Brunton's "Lectures on the Ac- tion of Medicines," Macmillan Co., Publishers.) freckles. Local Applications of Heat are, therefore, Contra-indicated and must not be used to relieve pain (1) when it is desirable to check suppuration as in appendicitis when the formation of an abscess would greatly increase the danger, and also in other cases (as in the beginning of a stye, or boil, or abscess in tooth or ear) when the object is to check abscess formation; (2) when infection is present as in a carbuncle (a honeycomb of boils) and the softening of the tissue caused by the heat would allow 196 THE PRINCIPLES AND PRACTICE OF NURSING the infection to spread or burrow deeper into the surrounding tissues. Reflex Effect of a Local Application of Heat.—It has been found by experience and by very careful studies and experiments Cuntfs. Stomach, — Kidneys, Bowels Pelvic Viscera. Fig. 31.—Cutaneous Areas Reflexly Associated with Internal Parts (From Kellogg's "Rational Hydrotherapy," Modern Medicine Pub- lishing Co., Publishers.) ELEMENTARY NURSING IN A MEDICAL WARD 197 that each internal organ (or the blood vessels supplying it) is reflexly related to some portion of the skin or body wall; that is, the nerves supplying these internal organs are very intimately associated through centers in the brain and spinal cord with the Brain ■Bowels and Ab- dominal Viscera ■Bladder, Uterus and Ovaries V"^- \....."I Genito-Urinary .[.«£2j>.\._. (Organs Brain and Lungs (Pelvic Organs (Intestines. Brains Fig. 32.—Cutaneous Areas Reflexly Associated with Internal Parts. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Pub- lishing Co., Publishers.) �415 3406 198 THE PRINCIPLES AND PRACTICE OF NURSING sensory nerves in definite portions of the skin. For instance, as shown in figures 31 and 32, the brain is related with the skin of the face, scalp, back of the neck, and also with the feet; the stomach is reflexly related with the skin over the epigastrium; the lungs are reflexly related with the skin over the chest; the intestines are reflexly related with the skin and body wall of the abdomen; the internal organs of the pelvis—uterus, bladder, colon and rectum—are reflexly associated with the wall of the lower abdomen or pelvis; the brain, lungs and upper respiratory tract, and the pelvic organs are reflexly associated with the feet. Through this intimate nerve connection, applications to the skin—whether of heat, cold, friction, mustard, or other irritant —which stimulate the nerve endings in it, will produce changes in the circulation of the internal organ reflexly associated with the skin area to which the ap- plication is made. The result is relief of congestion and the symptoms of distress due to it, such as pain, dyspnea, and cya- nosis in congestion of the lungs in pneumonia; or pain and sup- pression of urine in inflamma- tion and congestion of the kid- ney as in nephritis. By such ap- plications, also, the involuntary muscles of internal organs such as the intestines or the heart may be stimulated and made to contract so that distention of the intestines may be relieved, and the heart-beat may be made stronger and faster. That such relief is produced is a matter of common experi- ence, a well known fact, accepted by all authorities. Authori- ties, however, differ widely as to the way in which applications of heat or of such irritants as mustard, etc., bring about these beneficial results. Some believe that, through irritation of nerve endings in the skin, nerve centers in the brain are stimulated and that these cause the blood vessels in the skin to dilate thus draw- ing more blood to them, and cause the blood vessels in the inter- nal organ reflexly related with that skin area to contract thus driving blood away and relieving congestion as shown in figures 33 and 34. Others believe that, for instance, a hot application to the chest which makes it red, showing that the circulation is stimulated and flowing more freely, will have the same effect on the lungs; that is, the outflow of venous blood or waste products is stimulated and, also, the inflow of fresh arterial blood, thus Fig. 33.—Diagram to Show Con- gestion of the Lung. The pulmonary vessels are shown dilated and those of the thor- acic wall contracted. (From Brunton's "Lectures on the Action of Medicines," Mac- millan Co., Publishers.) ELEMENTARY NURSING IN A MEDICAL WARD 199 nourishing and reviving the tissues and increasing their resistance. As there is just a certain volume of blood in the body, it will easily be seen that, if a hot application draws a large volume of blood to one part of the body (as it does to the feet and legs in a hot foot-bath) it must necessarily reduce the blood supply in other parts of the body. Again it must be remembered that when heat is applied to cause contraction of involuntary muscles, as in the application of stupes to relieve distention by causing the contraction of the muscular wall of the intestines, the application must be very hot and the high temperature must be continuous throughout the treatment which usually lasts from 10 to 20 minutes. (See lo- cal effect of heat.) The Effect of Moist Heat — Moist heat is much more pene- trating than dry heat because water has a power of absorbing and communicating heat greater than that of air. Water is a much better conductor of heat, and, therefore, moist heat makes a much more intense impression upon the skin than dry heat. Applications of moist heat also prevent loss of heat either by radiation or evaporation (if kept covered) and this further inten- sifies the effect. LOCAL APPLICATIONS OF DRY HEAT. A HOT-WATER BAG Fig. 34.—Diagram to Explain the Action of Counter-Irrita- tion. A blister or other coun- ter-irritant is shown applied to the chest wall. The stimulus which it causes is transmitted up the afferent nerves to the vaso-motor centre; it is thence reflected down the vaso-motor nerves to the pulmonary ves- sels causing them to contract, while it is reflected down vaso- dilating fibres to the vessels of the thoracic wall and prob- ably of other parts of the body also, causing them to dilate and thus lessening the pulmo- nary congestion by withdraw- ing blood from the . lungs. (Compare with Fig. 33.) A hot-water bag may be used as a therapeutic measure in a variety of conditions among which are the following: (1) to relieve pain in toothache or earache by drawing blood to the face and so relieving congestion in the vessels supplying the tooth or ear; (2) applied to the abdomen to relieve pain due to con- gestion of the pelvic organs—the uterus, ovaries or bladder—and in dysmenorrhea; (3) applied over the bladder or to the peri- neum to overcome retention of urine; (4) applied to the abdo- men to relieve intestinal or renal colic; (5) to relieve pain in neuralgia and sciatica, etc. Method of Application.—The temperature of the water must 200 THE PRINCIPLES AND PRACTICE OF NURSING always be tested with a thermometer. It may vary from 120° F. to 150° F., depending upon the thickness of the cover used, the area to which the application is made, and the condition of the patient and the skin. It must never be hot enough to burn the patient should the bag leak or the rubber burst. To avoid such serious and inexcusable accidents, before use the bag must be carefully examined for leakage and for weak places in the rub- ber. The bag must always be completely covered with a suitable cover and the patient should be warned and watched to prevent him from removing it if he is likely to do so in the desire to relieve intense pain. The avoidance of unnecessary weight is extremely important. If the patient must support the weight of the bag, as when applied to the abdomen, it must not be filled more than one- third full and all the air must be carefully expelled from it. Even this light weight may be unbearable and may have to be supported by suspending it from a cradle or by some other means of relieving the weight. If the application is to be continued, see that the bag is regu- larly refilled and kept hot. Watch the position of the bag. The patient may be restless (particularly if in pain), displace the bag, roll over on it, and become badly burned. Do not leave the bag with the patient longer than the appli- cation demands. See that it is dried and put away in the proper place and in the proper manner. LOCAL HOT-AIR BATH This treatment consists in the application of superheated air to the affected part, such as an arm, leg, or knee-joint. It is called "baking" the part. Baking is used as a therapeutic measure in (1) inflammatory joints due to rheumatism; (2) inflammatory muscles; (3) chronic inflammation of joints with an exudate; (4) gonorrheal arth- ritis; (5) gout. Baking is contra-indicated in acute rheumatic fever or in any febrile condition, in acute inflammatory conditions, and in cases in which the skin of the part is broken or diseased. Effects of Baking.—The local application of hot air usually brings great relief and comfort to the suffering patient. It increases the temperature of the part because the hot air sur- rounding it prevents the loss of heat. All the activities of the cells or protoplasm are stimulated. Heat accumulates in the part and the temperature of the blood throughout the body may be raised. The surface blood vessels dilate; the skin become^ red; an increasing volume of blood flows through the surface vessels, thereby mechanically withdrawing blood from the adjoin- ing tissues or joints and thus relieving congestion. The affected part and the whole body perspire profusely because the increased temperature of the blood and the stimulation of the nerve end- ELEMENTARY NURSING IN A MEDICAL WARD 201 ings in the skin by the heat, together cause a stimulation of the sweat centers and heat regulating centers in the brain. These immediately set about preventing a further increase of body temperature by producing a profuse perspiration with an increased elimination of waste products. This increased volume of healing blood and leucocytes in the part aid in combating the infection and in stimulating the absorption of inflammatory products. The tendons, ligaments, and fascia are softened and expanded; the muscles are relaxed; pain is relieved, stiffness is removed, and the function of the part is restored. The Apparatus.—There are several forms of apparatus on the Fig. 35.—Frazier-Lentz Hot-Air Apparatus. (From Hare's "Practical Therapeutics," Lea and Febiger, Publishers.) market, so that the method of baking the part will depend upon the form of apparatus used and also upon the part of the body to be baked. These chambers are metal boxes lined with asbes- tos and containing an asbestos board or rest for the arm or limb. A thermometer is suspended in the chamber. The temperature of the air varies from 200° F. to 300° F. The duration of the treatment varies. It may be resorted to daily or several times a week and each treatment may last from a few minutes to several hours (usually one hour) depending upon the temperature used, the sensations of the patient and the nature of the case under treatment. Method of Procedure.—First see that the room is warm and that the patient is protected from chilling before, during, and after the treatment. The patient must be undressed (having 202 THE PRINCIPLES AND PRACTICE OF NURSING on a gown, wrapper, stockings and slippers) for the treatment, as it causes general profuse perspiration. Several blankets should be used to protect him from getting cold. His position and the position of the part being baked should be made com- fortable and all straining of muscles^from a cramped position avoided. Cold applications shouldM^applied to the head before, and during the treatment. The asbestos board or rest (which becomes very hot) should be covered by a pad of linen. The arm or limb must be pro- tected by a properly fitting flannel covering and not allowed to come in contact with either the asbestos or metal. No rings should be worn by the patient and no pins used in the protector as all metals are good conductors of heat and would burn the Fig. 36.—The Newell Hot-Air Apparatus. (From Hare's "Practical Therapeutics," Lea and Febiger, Publishers.) patient. The asbestos covering which guards the opening and a blanket should be snugly drawn around the limb. The tem- perature of the bath must be raised gradually. Both the tem- perature and the duration of the treatment may be increased from day to day as the patient becomes adjusted to it. The patient should never be left alone and should be watched closely for signs of weakness. He should be encouraged to drink fluids before and during the bath in order to encourage the elimination of waste products and to prevent the body tissues from suffering owing to the loss of so much water. At the end of the bath the limb should be well wrapped up with wool, covered with rubber cloth, and flannel, to continue the effect of the bath. Some doctors advise that the whole bodv have a short cold application such as a cold towel rub, followed ELEMENTARY NURSING IN A MEDICAL WARD 203 by careful drying and thorough rubbing. If the affected part will bear rubbing, some doctors also advise a very brief (four to thirty seconds) dry cold application (wring towel very dry before applying) followed by drying and vigorous rubbing. This acts as a tonic to the passively dilated blood vessels, and pro- longs the effects of the bath. In some cases the patient is put to bed between blankets, dried and given an alcohol rub. Be- cause of the free perspiration and weakening effect of the treat- ment the patient should always rest in bed following it. LOCAL APPLICATIONS OF MOIST HEAT. THE FOMENTATION OR STUPE The fomentation is a clean, efficient, and economical method of applying moist heat by means of two or more thicknesses of Fig. 37.—Diagram Showing Local Cutaneous Congestion, as in a Boil. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Pub- lishing Co., Publishers.) flannel cloth or old blanket wrung as dry as possible out of boil- ing water and applied directly to the skin a number of times in succession. The heat and moisture are retained by covering the application with a piece of dry flannel and rubber tissue or oiled muslin. It is essentially a local vapor bath. Fig. 38.—Diagram Showing Relief of Local Congestion by a Fomenta- tion Which Dilates the Surrounding Vessels. (From Kellogg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Pub- lishers.) For the effects of the fomentation see the effect of a local appli- cation of moist heat. Very hot applications, such as the fomen- tation also lessen the sensibility of the nerve endings in the skin and thus relieve pain. By their sedative effect on the nerve endings in the skin, they also relieve pain in deep seated, pain- 204 THE PRINCIPLES AND PRACTICE OF NURSING ful parts, if applied to a region of the skin associated reflexly with them through the nervous system. Fomentations are Used as a Therapeutic Measure:— (1) To relieve pain and congestion in the adjoining parts by their analgesic or pain-relieving effect on the nerve endings, Fig. 39.—Diagram Showing Collaterally Related Vascular Areas, Skin Overlying Muscle. (From Kellogg's "Rational Hydrotherapy," Mod- ern Medicine Publishing Co., Publishers.) and by mechanically drawing blood from the congested part to the skin. They are used for this purpose in strains or sprains of joints or muscles (if the skin is unbroken) ; in dislocations and fractures to relax the tendons, relieve pain and prevent swelling; in lumbago and sciatica; in rheumatic joints and muscles; in the very early stages of a boil in order to bring the healthy blood to the part and stimulate its vital resistance, and Fig. 40.—Hyperemia of Skin with Collateral Anemia of Underlying Muscle Produced by a Hot Application. (From Kellogg's "Rational Hydrotherapy." Modern Medicine Publishing Co., Publishers.) ELEMENTARY NURSING IN A MEDICAL WARD 205 in the later stages of a boil to promote suppuration,—caution must be observed because the heat softens and lowers the resis- tance of the tissues, so may cause the infection to spread and burrow deeper; in toothache and earache to dilate the vessels in the skin and relieve congestion, pressure and pain in the tooth or ear; in mastitis (with caked milk) in order to soften and expand the tissues so that the milk may be expressed; in ton- sillitis and laryngitis or croup. (2) To relieve pain and congestion in internal organs by their analgesic effect on nerve endings, by reflex action, and by draw- ing blood to the skin in the following conditions: In inflamma- tion and congestion of the kidneys with suppression of urine; in all pelvic congestions of the uterus, ovaries or bladder, and in dysmenorrhea; in acute gastritis and intestinal catarrh; in pneu- monia, pleurisy and acute bronchitis. (3) To relieve distention or tympanites in pneumonia, typhoid, peritonitis and post-operative cases by causing the con- traction of the smooth muscles of the intestines and the expul- sion of the gas. (4) To relieve intestinal and renal colic. (5) To reduce a swelling; to stimulate the absorption of effu- sions or exudates; to increase the local blood supply, promote leucocytosis and functional activity. (6) To accumulate heat and raise the temperature of the part. —It is now thought that the increased body temperature which occurs in infectious diseases is one of Nature's methods of defense against the invading enemy, a means of making the tissues an undesirable abode for those parasites "who unbidden eat at the table of another at his expense." In the same way it is thought that increasing the temperature of a locally inflamed part aids the tissues in their natural processes of defense. Fomentations are usually most effectual in the above condi- tions and give the patient prompt and great relief. Method of Procedure.—The essential factors to be considered in making the application in order to obtain the desired results are: 1. The Preparation of the Patient.—It is important to see that the patient is protected from exposure and chilling—an extra blanket for the chest, etc., should be used when necessary. Chilling of the body surface causes congestion of internal organs and the purpose of the treatment may be to relieve this. The extremities, particularly, must be warm. Some doctors advise that during the treatment cold applications should be made to the head, particularly if there is any tendency to congestion of blood in the head. The bed linen should be arranged conven- iently, avoiding exposure. It should be protected so as to avoid the possibility of it being dampened by the moist applications. This would chill the patient afterwards. 2. The Area to be Covered.—This depends upon the object: When the object is to cause an increased volume of blood 206 THE PRINCIPLES AND PRACTICE OF NURSING in the skin and relieve congestion in the adjoining parts or inter- nal organs, the fomentations must be very large so as to with- draw a large volume of blood. For instance, applications to relieve congestion in the kidneys must cover the whole central and lower part of the back and come well around to the sides; to relieve inflammation of joints, the application should be closely wrapped completely around the joint and extend several inches above and below it; to relieve pain in the stomach, the applica- tion must extend from the fourth rib to the umbilicus and between the two axillary lines; to relieve pain or congestion in pelvio organs, the application must extend over the whole lower abdo- men and well over the hips and thighs; to relieve pain, in ab- dominal organs, the application must extend from above the waist-line and well down over the hips; to relieve inflammation or congestion of the breasts, the application should be applied closely around the breasts but the nipple must never be covered. When applied for a purely local effect as in the relief of an infected finger or boil, etc., the application should not be larger than necessary, in order to avoid dilating the artery supplying the part and thus increasing the congestion. For instance, when the object is to relieve inflammation of the eyeball the applica- tion should cover the eye and extend over the brow (but not over the cheek) in order to dilate the artery supplying the eye- lids and forehead (the supra-orbital branch of the ophthalmic artery) and withdraw blood from the vessels of the eyeball; when applied to relieve toothache or earache, the application should be made to the face only (to draw the blood to the sur- face vessels) but should never extend below the jaw as this would dilate the carotid artery and its branches supplying the face and head and thus increase the congestion and pain. 3. The solution most commonly used is plain boiling water. Turpentine is frequently added to abdominal stupes as an added irritant for the relief of distention, etc. It is never used for fomen- tations applied for the relief of pain or congestion of the kidneys and suppression because the turpentine if absorbed would have to be eliminated by the kidneys, and as it is very irritating, would aggravate the already inflamed condition. 4. The applications are made by immersing soft pieces of flan- nel (the required size) in the boiling water until thoroughly saturated, then wringing them as dry as possible and applying directly to the skin. When turpentine stupes are ordered, the turpentine may be added to the boiling water in the proportion of 3 teaspoonfuls of turpentine to 3 pints of boiling water. The water is allowed to boil freely again before immersing the flannel. Another method of applying turpentine stupes is to thoroughly mix one part of turpentine to two or three parts of olive oil for adults, and one to six or ten for children. Apply this before every sec- ond or third fomentation or as often as the skin will allow. 5. The temperature of the applications will vary from 140° to ELEMENTARY NURSING IN A MEDICAL WARD 207 160° F. They are applied as hot as the patient can stand, that is, hot enough to cause pain when first applied. 6. The Care of the Skin and Protection of the Part.—The greatest care must be taken to prevent the skin from being burned. Wring the flannel as dry as possible. Apply it grad- ually and, if it causes too much pain, lift it up for a second and then replace it so that the skin may become gradually used to the extreme temperature. Oil the skin if tender, or if applica- tions are made frequently. This prevents burning or softening of the skin. Take special care in distention, when the skin is apt to be stretched, also when the part is paralyzed, insensitive or benumbed by cold—it is safer to apply the fomentations at a lower temperature or to use plenty of vaseline. Avoid chilling the part before, during or after the treatment. It is first covered with a soft, dry, warm piece of flannel, large enough to extend well beyond the area on all sides. All applica- tions are made beneath this flannel. Avoid currents of air or exposure during the applications, as this will cause loss of heat and chilling. Avoid any evaporation of heat or cooling of the part by using two hot fomentations in succession, applying one quickly as the. other is removed. 7. The duration and frequency of the treatment vary with the condition. The desired temperature may be maintained by changing the compress every two or three minutes during a period of from ten to twenty minutes. The applications are renewed every two, three, or four hours as the case may demand. In some cases one application is left on for fifteen to twenty minutes, then removed, a fresh application being made once each hour. The treatments will probably be continued as long as they give relief to the pain or other symptoms present. 8. After the removal of the last hot compress, dry the part and leave it covered with the soft, dry, warm flannel to prevent chill- ing, but do not have it sufficiently warm to cause perspiration. Oil the skin if very red or tender. 9. When fomentations are applied to the abdomen for the relief of distention, an order is usually given to insert a rectal tube into the rectum before beginning the treatment and to allow it to remain during and for some time after. The free end of the tube must be in a receptacle in the bed because fecal matter is frequently expelled with the gas. Chart the treatment as given and its effects on the patient. A POULTICE OR CATAPLASM The poultice is an application of moist heat in the form of a soft paste which retains its heat for a varying length of time according to the ingredient used. The good effects of the poul- tice depend mainly upon the heat. The ingredients commonly used are flaxseed or linseed, bread, hops and digitalis. Flaxseed is the best because of its muci- 208 THE PRINCIPLES AND PRACTICE OF NURSING laginous and oily ingredients. It is more soothing to the skin, may be used at a higher temperature without burning, retains its heat longest, and air can be readily incorporated in it, mak- ing it light and more bearable to the patient. The effects of the poultice are the same as those due to the fomentation and, like the fomentation, usually give the patient great relief and a sensation of comfort if properly applied. If not properly applied it causes discomfort and may do harm. Poultices are used for purposes similar to the fomentations, but are most commonly used as a therapeutic measure in the follow- ing conditions: (1) Pneumonia, to stimulate the absorp» LOCAL AND GENERAL APPLICATIONS OF COLD Some of the uses and effects of cold and the forms in which cold may be applied have been briefly discussed in an earlier chapter. As cold applications are used in a great variety of conditions and for patients often acutely ill, their uses, effects and forms of application will be more fully discussed in the present chapter. Local applications of cold are made by means of an ice-bag, an ice-coil, cold compresses or volatile sprays. They are used in the treatment of both medical and surgical diseases. Purposes for which Local Cold Applications may be Used: I. To produce a purely local effect on the tissues to which the application is made. II. To relieve inflammation, congestion, hemorrhage or pain in a part by controlling the circulation to it. III. To produce the desired effect on some internal organ or distant part reflexly associated with the area of skin to which the cold is applied. I. Applications are made for a purely Local Effect on the Superficial Tissues when used for the Following Pur- poses: 1. To check inflammation and congestion; to prevent or re- duce swelling; to relieve pain; to check bleeding and discolora- tion in such conditions as a bruise, wound, burn, sprain, fracture, acutely inflamed joint, hemorrhoids, phlebitis, tonsilitis, diph- theria, etc. 2. To check inflammation and prevent suppuration or abscess formation in infected wounds, an infected finger, a stye, boil or abscess in a tooth or ear. Effects Produced by the Above Applications.—1. The cold first causes the numerous small involuntary muscles in the skin to contract and the pressure exerted by these contracting muscles squeezes the blood out from the capillaries in the skin. (It is the contraction of these smooth muscles which gives the familiar appearance of gooseflesh.) 2. The cold, also, stimulates nerve endings in the skin and 374 LOCAL AND GENERAL APPLICATIONS OF COLD 375 through these nerves the vasomotor center (the center in the brain controlling the size or caliber of the blood vessels) is stim- ulated and this center, in turn, causes the small blood vessels in the skin to contract, thus squeezing out more blood from the skin; this is called a reflex act. 3. There is, therefore, less blood in the skin so that it becomes pale. 4. Unless the application is prolonged, there will be more blood in the adjoining and underlying tissues, as shown in figure 46. 5. An inflammatory process, if present, is thus checked be- cause, if you remember, the first step in this process upon which the succeeding steps depend, is an increased supply of blood to the part. Thus there is less redness and heat in the part; con- gestion, swelling and pressure on nerve endings and thus pain are relieved; all activity in the cells of the part is depressed— the secretions are checked, the growth of bacteria (which are made up of protoplasm, like the body cells) if present, and sup- puration, are checked. This is called the Primary Action of cold. Effect of Applications in the Above Conditions if Too Pro- longed.—1. Cold applications if intense or continued for a num- ber of hours will destroy all sensation in the part because cold depresses the activity of nerve tissue as it does that of all other tissues. Pain is thus relieved. Surgeons sometimes freeze the part by using ethyl chlorid, a volatile spray, to cause insen- sibility to pain, in minor surgical operations such as incising a boil or an abscess. This is called a local anesthetic This loss of sensation is due to the effect of cold on the nerve cells. It is thought that the cold causes the nerve cells to retract their branches which normally interlace (although quite distinct and not connected), and by means of which the messages are car- ried from nerve cell to nerve cell until they reach the brain. This retraction of the branches would interfere or "break the connection" just as an electric current or telephone message may be interrupted if wires are disconnected or broken. 2. If the nerves are completely benumbed, they will then fail to carry messages to the vasomotor center which will, therefore, fail to contract blood vessels in the skin. 3. The thin, weak-walled veins first become exhausted, relaxed and congested, allowing venous blood to collect and preventing the entrance of fresh blood. The part becomes blue or purplish. If allowed to continue this would interfere with the supply of food and oxygen, lower the resistance of the cells, interfere with healing and even cause the death of the already damaged tissue. 4. Again, the temperature of the part may be so lowered that the cells are unable to function because a certain degree of heat is necessary for the chemical changes which mean life and work. If these changes are completely checked not only loss of func- tion but death follows. 5. Prolonged applications cause a lowered temperature and lessened activity of the cells in adjoining tissues and muscles so 376 THE PRINCIPLES AND PRACTICE OF NURSING that the part, the fingers, for instance, will become blue, numb, stiff and clumsy with the cold. This depressing effect of cold on all living things is familiar to all. The sturdy plants wither at the first touch of frost— some never revive again, others revive with renewed beauty and vigor in the warm spring sunlight. You remember, also, how the bear sleeps away the long winter, during which time we are told the pulse may be only eight per minute and the respiratory chest movements entirely suspended. The use of ice to preserve food from decay by checking the activity and growth of bacteria is a common practice. This danger of injury, death and sloughing of the tissues as a result of cold applications must always be remembered by the nurse and the first symptoms—a blue, purplish, mottled appear- ance of the skin, with numbness—should be reported to the doc- tor and the application removed. This indicates that the cir- culation in the part should be stimulated, not checked. Alternate Applications of Heat and Cold.—Sometimes hot and cold applications are applied alternately as in the treat- ment of a sprain; or a cold moist application may be made and allowed to remain on the part until warmed to body temperature and almost dried, then renewed by a second cold application. Such an application is frequently made to the throat in the treatment of tonsillitis. The effect is first a contraction and toning up of the blood vessels and lessening of the blood supply in the part, thus relieving congestion and pain. As the com- press warms, the blood vessels again dilate bringing fresh blood to the part, while at the same time the warmth has a very sooth- ing effect on the nerves. This alternate contraction and dila- tation of blood vessels with the constant withdrawal of wastes and renewal of the blood supply gives great relief to the patient, stimulates the absorption of inflammatory products, and greatly promotes healing. The effect of cold applications on mucous membranes is the same as that on the skin, except that the mucous membrane, having fewer sensory nerves (nerves which carry sensations) is not so sensitive to either heat or cold. The local effect may be seen by holding ice in the mouth. The lining will become pale; bleeding, if present, will be checked; nerves will become benumbed so that the sensation of taste or pain is lost. A piece of ice held in the mouth before the admin- istration of medicine with a disagreeable taste will make it much less distasteful. Dentists anesthetize or destroy the sensation of pain by freezing the gums, not by using ice, but a volatile liquid which in evaporating extracts heat from the gums so that they become frozen. Cold Applications are contraindicated in the following con- ditions.—1. When the skin is already discolored showing a stasis and congestion of venous blood. Cold is usually applied only when the skin is red, that is, in the early stages of inflammation. LOCAL AND GENERAL APPLICATIONS OF COLD 377 2. When a large area of tissue has been injured as in an exten- sive bruise or burn or a wound in which the tissues around are bruised. In such cases many cells have been injured and the discoloration which quickly follows shows that blood vessels also have been injured, allowing the blood to escape into the tissues where it decomposes. Further interference with the cir- culation and nutrition may cause death of the tissues. Prompt stimulation of the circulation (usually by heat) may be neces- sary to prevent this. 3. When pain is very severe. Heat usually gives greater com- fort. The doctor is often guided, in the use of heat and cold, by the patient's sensations, that is, by which gives the greater relief. 4. In inflammation of muscles and of the eyeball, in chronic inflammation of joints and deep-seated abscesses, in toothache or earache when the contraction of the blood vessels in the skin would increase the blood supply and congestion in the adjoining inflamed parts. In all of the above conditions, heat is usually applied to stim- ulate the circulation, to bring fresh, healing blood and to carry away the dead cells and other wastes. Heat will promote the absorption of the waste products or will promote suppuration so that the dead mass or slough will be liquefied and separated from the living tissues in order that healing may more quickly take place. II. Application made to relieve Inflammation, Congestion, Hemorrhage or Pain by Controlling the Circulation to the Part.—Sometimes it is necessary to control the circulation in a part without making applications directly to it. This may be done by applying cold to the trunk of an artery between the heart and the injured part or to the blood vessels directly sup- plying it. For instance, an ice-bag in the axilla or bend of the elbow will check hemorrhage or relieve congestion in an injured hand; an ice-bag in the groin or bend of the knee will have the same effect on the leg or foot; cold to the throat, by contracting the carotid arteries, will relieve inflammation in meningitis, also sleeplessness or headache due to cerebral congestion or excess blood in the head; cold to the head and face will have the same effect. Cold to the face and back of the neck will relieve nasal catarrh or epistaxis (bleeding from nose) ; cold to the side of the neck below the jaw will sometimes relieve toothache and earache. The Reflex Effect of Local Cold Applications.—It is thought that when the applications are made to a small skin area (as with an ice-bag) the effect produced on the internal organ re- flexly associated with it is the same as that produced on the skin. The cold stimulates or irritates nerve endings in the skin, thereby stimulating the vasomotor center in the brain which, in turn, causes the contraction of the blood vessels in the reflexly asso- ciated internal organ. III. Applications are made to produce the Primary Action 378 THE PRINCIPLES AND PRACTICE OF NURSING of Cold, by Reflex Action, on some Internal Organ or Distant Part when Used for the Following Purposes: (1) To contract blood vessels and check hemorrhage in inter- nal organs.—An ice-cup, coil, or compresses may be applied to the head to check a hemorrhage in the brain as in apoplexy; to the chest to check hemoptysis (bleeding in the lungs and cough- ing up blood); to the epigastrium, to check hematemesis (vomit- ing of blood); to the abdomen, to prevent or check hemorrhage in the intestines in typhoid. The ice-coil is the most desirable form of application because it is light, flat and more adjustable, feels more comfortable, less of a burden, and ice-water can be kept flowing through it continuously so that the temperature is constant. Applications used to check hemorrhage must be absolutely continuous until all danger is passed, otherwise there is apt to be a reaction with increased bleeding. (See secondary or tonic reaction.) Authorities differ as to the penetrating effect of cold on the deep tissues. Some believe and feel that they have proved by experiments that the cold actually penetrates and affects deeper tissues. For instance, some believe that an ice-bag applied to the abdomen will in this way check hemorrhage in the intes- tines, while other authorities feel that their experiments prove that the deeper tissues are not affected in this way, but only by reflex action. (2) To contract blood vessels in the head and relieve inflam- mation and congestion in meningitis, etc. An ice-bag is applied to the head in all general baths (either hot or cold) to contract the blood vessels so as to avoid possible congestion due to a sud- den inrush of blood from the contracted skin vessels. An ice- bag or cold compresses to the head will also relieve headache or insomnia due to congestion or excess blood in the head. (3) To relieve pain, inflammation and congestion of internal organs, cold may be applied to the chest, abdomen, or pelvis. In acute appendicitis with severe pain in the abdomen the appli- cation of an ice-bag will completely relieve the pain and "mask" the symptoms. For this reason, surgeons sometimes consider the application inadvisable because the patient's symptoms must be their guide in determining whether he should be operated upon immediately or not. (4) To relieve vomiting and pain due to cancer or gastric ulcer cold may be applied to the epigastrium. (5) To cause the contraction of the intestinal muscles and relieve distension in typhoid, the ice-coil may be applied to the abdomen. (6) To depress the activity of the heart muscle when the pulse is rapid and irregular. A "continuous" ice-bag to the pre- cordia (the region of the chest over the heart) will act as a sedative to the heart muscle, lessening its irritability and pain, making the pulse rate more slow and steady, thus resting the heart. 2 Fig. 118.—Diagrammatic Illustration of Gastric Con- gestion. 1, Arteries greatly congested. 2, Cutaneous area reflexly related with the stomach. 3, Nerve trunk connecting this area with the spinal center con- nected with the stomach. 4, Sympathetic and vaso- motor nerves which transmit to the stomach the sen- sory impulses received from the skin. (From Kel- logg's "Rational Hydrotherapy," Modern Medicine Publishing Co., Publishers.) Fig. 119.—Diagrammatic Illustration of the Effect of Cold Applied to the Cutaneous Area Reflexly Con- nected With the Stomach in Case of Gastric Con- gestion or Inflammation. (From Kellogg's "Ra- tional Hydrotherapy," Modern Medicine Publishing Co., Publishers.) 380 THE PRINCIPLES AND PRACTICE OF NURSING (7) To depress nerve centers as a sedative to the nervous system. An ice-bag or coil applied continuously to the head will depress mental activity (bone is a good conductor of cold). Either may, therefore, be used to lessen mental excitement, de- lirium or insomnia in meningitis, typhoid and other febrile con- ditions. This depressing effect of prolonged contact with cold is well illustrated in those frozen to death in whom it is well known that after the first intense suffering there is no conscious- ness of pain, but only of an irresistible desire to lie down and sleep. Important Factors to Remember.—In making the above applications, in order to produce the desired effect (the primary effect of cold) on the internal organs, it is essential to remember the following important factors: 1. The application must be small otherwise the desired reflex effect (contraction of internal blood vessels) will not be obtained. Large applications to the skin (particularly when made to the whole body as in a general bath) by contracting many blood vessels may drive in so much blood that the internal vessels can- not contract and may even become further congested. When the application is made to a small area the blood driven in by the contracted skin vessels is small in amount and is spread over the blood vessels of the whole body, whereas the reflex effect is concentrated on the internal organ reflexly associated with the skin area treated. 2. The application must be prolonged in order to maintain the primary effect. Otherwise when the application is removed or if the temperature is not maintained, it will be followed by a reaction. This reaction is called the secondary effect of cold, or the "tonic reaction." This tonic reaction is frequently the reflex effect desired. 3. While the applications may be prolonged, it is very impor- tant to watch for and avoid a bluish, mottled skin or numbness, not only because of danger to the tissues, but because no reflex effect can take place. When the nerves in the skin are benumbed they cannot carry any messages to the brain so that nerve centers are not stimulated and no reflex action occurs. Remember that the beneficial effect on the internal organ depends upon this reflex action. To prevent loss of reflex action (and injury to the tissues), when an application must be prolonged, the doctor frequently directs that it be removed at stated intervals and the part rubbed until warm and red, or that a hot application be made to restore the circulation and activity of nerves. The skin should always be warm before cold applications are made. 4. When cold applications are made to the head, chest, abdo- men or pelvis to relieve inflammation or congestion, the feet must be warm. Cold feet will cause congestion in these parts. The reflex relation of the feet to the internal organs, upper respira- tory tract and head explains why "getting the feet wet" seems LOCAL AND GENERAL APPLICATIONS OF COLD 381 to predispose to so many ills such as colds, pneumonia, cystitis, nephritis, intestinal catarrh, amenorrhea, and dysmenorrhea, etc Hot and cold applications are frequently used together. For instance, an ice-bag may be applied to the head to relieve a headache due to congestion, or a hemorrhage as in apoplexy, or to the abdomen to relieve inflammation and congestion in the pelvic organs, while hot applications are made to the feet to dilate the blood vessels and draw the blood away from the head or pelvis. Cold Applications are made to produce the Secondary Effect or Tonic Reaction when used for the Following Purposes.— 1. To stimulate the heart.—Short, cold applications over the heart (an ice-bag applied for one-half hour three times a day or every two or three hours) act as a tonic to the heart muscle, slow the pulse, increase its force and raise arterial tension. 2. To stimulate the nerve centers in the brain.—Brief, cold applications to the head cause increased mental activity. For instance, fresh air or dashing cold water in the face will arouse from fainting, and cold to the head, a bracing breeze, or breath- ing cold, fresh air will arouse from dullness or stupor. This explains why students in studying sometimes wrap a cold towel around the head. It also explains the importance of fresh air in such diseases as typhoid and pneumonia in which the vital nerve centers are poisoned and depressed by toxins, etc. 3. To stimulate secretions, peristalsis and absorption in the digestive tract.—The habit of drinking a glass of cold water first thing in the morning, with some people, will prevent constipa- tion due to the increased tone produced in the muscles of the intestines. This is the "tonic reaction" explained in the following paragraph. Effects Produced by the Above Applications.—The primary effect of cold applications has already been explained. It is an effort on the part of the body to protect itself from injury, from anything which interferes with its ability to "carry on." It has been seen that cold is a vital depressent interrupting and inter- fering with the work of every tissue with which it comes in contact. When in contact with cold, therefore, the body must protect itself. The nerve endings (sentinels or guards) in the skin imme- diately warn their chiefs, the vasomotor and heat-regulating centers in the brain. These rally their forces which set about preventing any further loss of heat and producing more heat to make up for that lost. For instance, you gasp and shiver when in contact with cold, due to the contraction of muscles. This is Nature's way of producing more heat. Perspiration stops and the skin becomes pale because the blood vessels contract, driving the warm blood to internal vessels. This is Nature's way of pre- venting further loss of heat. If the application has not been too prolonged, or if the tissues 382 THE PRINCIPLES AND PRACTICE OF NURSING are not too depressed, they not only quickly resume all their normal functions when the cold application is removed, but in the enthusiasm of their defense, are stimulated to increased vital activities, as though "every knock were a boost." Sometimes even before the removal of the application, particularly if accom- panied by friction, this tonic reaction sets in. We are all familiar with this tonic reaction as a matter of common experience. For instance, when first going out of doors on a cold winter's day, one may feel chilly and shiver. The face may look pale and pinched, and the teeth may even chatter. After a short time, however, in a healthy person this feeling of discomfort is replaced by a sensation of warmth, comfort, and well-being. The Tonic Reaction.—The narrowing of the blood vessels in the skin and the stimulation of the vasomotor center, previously mentioned, each cause the heart to beat with increased force in order to overcome the resistance to the flow of blood caused by the contracted blood vessels. Thus the vasomotor center (which causes the contraction of blood vessels) and the heart are both stimulated and the circulation is improved. An abundance of warm blood is forced back into the capillaries of the skin, giving it a warm healthy flush. This internal application of warmth offsets the external application of cold so that the involuntary muscles of the skin relax somewhat, thus removing to a certain extent the pressure on capillaries and small blood vessels. The stimulated heart continues to drive more blood into the capil- laries and small blood vessels. The muscles in the skin and blood vessels, however, keep up their tone and state of contraction, maintaining a certain pressure and resistance to further disten- tion. The heart must continue to contract with force, and the contracted blood vessels keep the blood moving onward, so that increased blood with its nourishing and healing properties flows freely through the part and carries away with it all the waste products. Life is renewed and all the activities and defensive properties of the cells are stimulated, giving increased strength, vigor, and resistance in the part. This is the tonic reaction. It occurs not only in the skin and adjoining tissues, but in the inter- nal organ reflexly associated with it. A pink, warm flush to the skin and the sensation of comfort following, together with the relief of symptoms and the improved function of the internal organ are the indications that this tonic reaction has been produced. This tonic reaction also occurs in nerve tissue. Sometimes we have cause to regret this. For instance, when the gums are frozen to extract teeth, and the tonic reaction sets in, the nerve endings will be much more sensitive to pain and the sensation will pass from nerve cell to nerve cell with increased ease and rate so that the pain may be unbearable. This is what makes a frozen part —fingers, ears, nose or toes, etc.—so very painful when, as we say, it is "thawing out." The nerves previously numbed have become increasingly sensitive and the blood, previously driven LOCAL AND GENERAL APPLICATIONS OF COLD 383 out of the tissues, returns in increased volume so that the part becomes red and swollen. This causes pain also, by pressure on the sensitive nerve endings. This tonic reaction also explains why frozen parts must be thawed out very gradually and why you should not come near the fire nor apply heat. The heat would relax the weakened blood vessels to such an extent that the blood would rush back in such increased volume that many capillaries would rupture and cause bleeding into the already severely damaged cells. The heat would also soften the tissues. The result would be death and sloughing of the part. To thaw the part gradually you rub with ice or snow so as to try to stimu- late or revive the nerve endings and bring about a tonic reaction. This will keep up the tone and contraction of the vessels and allow a more gradual supply of blood and restoration of the cir- culation. The temperature of the part and activity of the cells will then gradually be restored. If this tonic reaction does not occur, the tissues have been so injured and depressed that they have died and must slough away. Remember that this disastrous effect may be produced, through ignorance or carelessness on the part of a nurse, by intense or prolonged cold applications if not properly applied. LOCAL APPLICATIONS OF COLD The method of applying an ice-bag has been discussed in Chapter XVI. THE ICE-COIL The ice-coil is a convenient substitute for the ice-bag when cold is to be applied continuously. It is lighter, more pliable, may be more easily fitted to the part and the temperature can be kept constant. It consists of a flat coil of rubber tubing, with two loose ends about two yards long, through which cold water is passed. Conditions in which the Ice-Coil is most Commonly used.— 1. Applied to the head in fevers, meningitis, cerebral hemor- rhage and conditions accompanied by cerebral congestion to con- tract the blood vessels, check bleeding, inflammation and con- gestion, and to act as a sedative in delirium. 2. Applied to the chest in hemoptysis, pleurisy and pneumonia to check bleeding, inflammation, and congestion; to relieve pain, dyspnea and coughing, and to calm an irritable heart and slow the pulse in pneumonia. The cold increases the tone in the muscles of the heart and blood vessels, and improves the circu- lation. It increases leucocytosis, the elimination of toxins and vital resistance in the part. It stimulates vital nerve centers, relieves toxemia, and lowers the temperature. It induces sleep, improves the appetite, and the function of the kidneys. 3. Applied to the left side of the chest in endocarditis, in peri- 384 THE PRINCIPLES AND PRACTICE OF NURSING carditis, and in fevers, such as typhoid and pneumonia, with a rapid, bounding pulse. 4. Applied to the abdomen in typhoid fever to cause the con- tinuous contraction of the mesenteric blood vessels and prevent or control hemorrhage and congestion and the action of bacteria. It increases vital resistance in the part. It also keeps up the tone and contracts the muscles of the intestines and prevents distention. Method of Application.—When an ice-coil is to be applied a bucket containing water and ice is placed on a chair or stand at the side of the bed. The ice should be covered with gauze to prevent any particles from the melting ice from clogging the tub- ing. A second bucket or pail is placed on the floor or on a low stool for the return flow. The air may be expelled and suction created in the tubing by first attaching a funnel to the end through which the water enters and pouring water through. Be- fore it has all quite run through, the end of the tube should be placed in the water in the bucket on the stand. The ice water should then run continuously. The water in the pail on the floor may be poured back into the bucket and kept at the right tem- perature by adding ice to it. Sometimes instead of a bucket and flow of water by siphonage, a water cooler is used from which water flows by gravity. Preparation of the Patient.—As in all cold applications, the patient's feet and body must be warm and the application must not be allowed to cause prolonged chilly sensations. The area to which the cold is applied should be warm before the application is made. To protect the skin from the intense cold, a moist com- press is placed between it and the coil. The skin must be closely watched for discoloration and numbness. THE COLD COMPRESS Cold compresses may be applied to the head, chest or abdomen in the same conditions and for the same purpose as the ice-coil. COLD HEAD COMPRESS Method of Application.—Cold compresses to the head are usually applied to the forehead only. They may be used in addi- tion to an ice-cap applied to the head. The compress may be made of several thicknesses of gauze or old muslin in order to retain the cold longer. If made of gauze all raw edges should be turned in so as not to annoy the patient. Compresses should be kept moist and changed frequently enough to maintain the desired temperature. A basin containing a block of ice and a small amount of water should be kept at the bedside. While one compress is on the head a second one should be moistened and placed on the block of ice so that it will be ready for use. Fig. 120.—Diagram Showing: A, Pulmonary Congestion; B, Beneficial Effect of Cold Chest Compress. (From Kellogg's "Rational Hy- drotherapy," Modern Medicine Publishing Co., Publishers.) 385 386 THE PRINCIPLES AND PRACTICE OF NURSING The compress should be cold and moist when applied, but not moist enough to drip and dampen the pillow. COLD CHEST COMPRESS The cold compress to the chest may be used for the same pur- poses and in the same conditions as the ice-coil, but is most com- monly used in pneumonia. The purpose of the application is (1) to improve the circu- lation and increase vital resistance in the lungs; (2) to relieve pain, dyspnea and coughing; (3) to improve the tone of the muscles of the heart and blood vessels; (4) to stimulate the Fig. 121.—Sphygmographic Tracing Showing the Effects of the Cold Cardiac Compress in Raising the Blood Pressure, (a) Before Ap- plication (Tension Low), (b) After Application (Tension High). (From Kellogg's "Rational Hydrotherapy," Modern Medicine Pub- lishing Co., Publishers.) vital nerve centers, to relieve toxemia, to lower the temperature and to induce sleep; (5) to improve the appetite and the func- tion of the kidneys and other organs. Method of Application.—The compress usually consists of about three layers or folds of old linen. The thickness must be sufficient to retain the moisture. It is cut and shaped so as to snugly fit the area to be covered. The method used sometimes calls for a piece of thin, soft, closely woven flannel, cut the same shape, but about one inch wider and longer to cover the wet com- press. Two such compresses and flannels will be required so that when changing the application the fresh compress may be applied quickly and without exposure of the part. Exposure allows evap- oration, chills the part and interferes with the desired reaction. Two sets are also necessary to allow the compresses to be washed and boiled at least once in twenty-four hours. This is essential for cleanliness and to prevent the possible danger of infections LOCAL AND GENERAL APPLICATIONS OF COLD 387 such as furuncles. Compresses are always thoroughly rinsed in a second basin of water before re-applying. The size of the compress depends upon the area to be covered. The area should always be prescribed by the doctor. The com- press may be applied to the anterior chest only or to both the anterior and posterior chest. In all cases the compress should be shaped at the neck and arms so as to snugly fit the part, and should extend from above the clavicles to below the umbilicus. The shouLders should be well covered and the compresses should extend well around at the sides. When the whole chest is covered it is often more convenient and disturbs the patient less to have separate compresses for the anterior and posterior chests. They should overlap on the shoulders and under the arms. The temperature and duration of the application should always be ordered by the doctor as they must be regulated to suit the individual case. These factors will depend upon the patient's temperature and general condition, and upon the effect desired, which may be either a tonic or sedative effect. The purpose may be to relieve stupor, or excitability, delirium and sleeplessness. The temperature is usually about 60° F. and the compresses are as a rule changed once every hour as long as the patient's tem- perature continues high. Reaction usually occurs within one hour, that is, .the skin and compress become warm. A nurse should previously ascertain from the doctor what steps are to be taken should reaction not occur within that time. The compress is usually removed, and the skin warmed (by gentle friction or by leaving the part covered with the flannel) before making a fresh application. A lower or higher temperature may be or- dered. When a sedative effect is desired a higher temperature may be ordered and the compress may be left on for two hours or more until dry and warm. Preparation of the Patient.—The bed must be protected as the compress is quite damp when applied. The patient is sometimes placed between blankets or the under sheets of the upper part of the bed only are protected and the upper bedding is turned down to below the waist. Again, as in all cold applications, it must be remembered that the patient's feet and body must be warm, and the area to which the application is to be made must also be warm. Otherwise the desired effect will not be obtained. To make the application the compress is wrung out of the water so that when applied it will be damp but not dripping. The flan- nel (when used) and wet compress should be applied together so as to avoid unnecessary disturbance of the patient. He should be turned very gently and quietly without exertion. The com- press must be smooth, free from wrinkles or bulky folds, and must be in close contact with the skin of the whole area. Other- wise pockets of air will form and cause evaporation with chilling of the chest and the whole body. While the application fits snugly it must not be tight enough to embarrass the breathing. As a rule, no covering, except the thin piece of flannel, is allowed 388 THE PRINCIPLES AND PRACTICE OF NURSING over the chest and compress. The effect desired is, by stimula- tion of the nerve endings in the skin and by reflex action, to bring an increased volume of blood to the skin vessels until the part becomes red and warm, and to allow the heat to gradually evap- orate through the thin flannel. To add further covering would cause the heat to accumulate and give the effect of a hot poul- tice. However, the patient must not be allowed to become chilly. When the treatment is combined with "cold air treatment" the patient's arms may be wrapped in flannel or, in some cases, a thin blanket may be spread lightly over the upper part of the patient or may extend to the foot of the bed under the bedding. A hot- water bottle may be placed at the feet. GENERAL COLD BATHS AND PACKS General applications of cold to the body are made in the form of cold packs, sedative packs, cold tub baths, cold sponge and slush baths. The effects of the applications will depend upon (1) the tem- perature of the bath; (2) its duration; (3) the form and method of application; (4) the condition of the patient. Effects of a Brief, Intense, General Application.—The appli- cation will be followed by both a primary action and a secondary or tonic reaction. These will be similar to those which follow local cold applications but will be much more intense and will affect the whole body. GENERAL APPLICATIONS OF COLD Effects of a Brief, Intense, General Application:— The primary action.—The blood vessels of the skin and viscera contract simultaneously to prevent loss of heat from the body. The skin becomes pale and cool. Perspiration is checked, pre- venting loss of heat. The blood flows more slowly through the contracted vessels of the skin so it becomes pale and pinched. To make up for the chilling of the blood at the surface, the energy and tone of the voluntary muscles are increased so they con- tract and cause shivering with sometimes trembling, chattering of the teeth, and even painful and distressing symptoms. The body temperature may be raised. This explains why applica- tions must be more prolonged to secure a drop in temperature, because they must be long enough to depress the heat-producing center. A very brief application will stimulate it. The blood vessels of the head and viscera quickly dilate, owing to the sudden inrush of blood from the contracted skin vessels in contact with the cold. (For this reason cold applications should always be applied to the head before and during general appli- cations.) In this way brief cold applications relieve congestion in the viscera by stimulating the rate of the flow of fresh blood to them and the removal of the products of waste and disease. The pulse is first quickened, then checked. The respirations are LOCAL AND GENERAL APPLICATIONS OF COLD 389 first checked (and may be gasping), then quickened, then be- come slower, fuller and deeper. The involuntary muscles of the stomach, intestines and bladder, etc., are stimulated. Those of the skin also contract producing gooseflesh. The leucocytes of the blood are increased. The nervous system is depressed. The secondary effect or the tonic reaction should follow imme- diately. The blood vessels of the skin dilate, those of the inter- nal organs mechanically contract. The skin becomes red, smooth, soft and warm. The patient has a general sense of comfort and well-being. Perspiration is increased. The pulse is slower with increased tension and force. Increased oxygen is absorbed in the lungs with increased elimination of carbon dioxid. The kidneys are stimulated and more waste products are eliminated. The liver is stimulated, also digestion and absorption in the alimen- tary canal. The mind is stimulated, the patient becomes brighter and more normal, the body temperature falls. The beneficial effects following cold applications are chiefly due to the thermic reaction, that is, the reaction following the stimulation of thermic nerve endings in the skin, in the effort to replace the heat lost by exposure to the cold and to restore the body to normal. Not only the heat-producing organs, the muscles and glands, etc., are stimulated but the activities of every cell and tissue in the body. The appetite, digestion and absorption are improved, the blood flows more freely and all the vital functions are restored and quickened. This is the "tonic reaction" following cold applications. Effect of Prolonged General Cold Applications.—A pro- longed cold application results in a continued contraction of in- ternal blood vessels unless the nerve endings in the skin become numb or lose their sensibility so that all reflex effect is lost. When this happens—indicated by the bluish, purplish skin—the congestion in the internal organs is increased and a great deal of harm may be done. This very undesirable effect may be avoided by removing the cold application every half hour and either rubbing the part or applying heat to restore the circulation in the skin. As cold is a depressant, prolonged applications depress cellular activities—the longer the application, the longer the depression that follows. Sooner or later, however, the parts will return to normal and if not too depressed, the "tonic reaction" follows. Thus we see that cold may be so applied as to secure its pri- mary, sedative effects or its tonic, stimulating effects. Friction and percussion are mechanical irritants or stimulants, either one or both of which are essential in promoting the tonic reaction following cold applications. Friction may be employed.—1. Before cold applications, to stimulate the circulation in the skin, to promote the reaction and so avoid distressing symptoms. 2. During the application to stimulate the circulation and tn prevent the nerve endings from becoming numbed, with resulting loss of reflex action. 390 THE PRINCIPLES AND PRACTICE OF NURSING 3. Following the treatment, if necessary, to insure the reaction with reddening and warmth in the skin. Conditions which Promote the Desired Reaction.—Before the bath means should be taken to stimulate the circulation in the skin and body generally. The skin should be warm and well reddened. This may be accomplished by exercise or friction of the skin, by a hot bath or hot drinks and by warm clothing. The air of the room should be warm. General health and vigor favor reaction. During the bath the lower the temperature of the water the more prompt the reaction. Short sudden applications also favor reaction. Friction or some form of pressure or percussion (the douche or spray) are essential. Following the bath reaction is promoted by heat in the form of hot, dry air, hot drinks and warm clothing. It is even possible to induce reaction in frozen parts by rubbing with snow or ice in a warm room. The lumberman in the north woods warms his feet by taking off his shoes and stockings and rubbing his bare feet with snow, immediately dressing them again. Friction with the hand or a rough towel and exercise favor reaction. Conditions which Discourage Reaction.—Very young chil- dren and old people react badly. Old people in whom arterio- sclerosis has begun react with difficulty and thus require special care. Very cold baths should be avoided. Exhaustion, either physical (from excessive exercise) or nervous (from loss of sleep) or extreme nervousness from any cause prevents reaction, owing to the weak condition of the nerve centers upon which prompt reaction depends. Profuse perspiration, a rheumatic tendency, an inactive skin, a cold skin or an extreme aversion to cold all discourage reaction. THE COLD PACK This consists in wrapping the body in a cold wet sheet and, except when used to reduce the body temperature, wrapping the patient carefully in dry blankets to prevent evaporation. The effects produced will depend upon the length of the applications as they occur in successive stages, each stage depend- ing upon the amount of heat allowed to accumulate. These stages occur in the following order: (1) The cooling stage which may be tonic or antipyretic; (2) the neutral or sedative period; (3) the heating or exciting stage, and (4) the sweating stage. I. The cooling stage is characterized by contraction of the blood vessels, causing a sensation of chilliness, its duration vary- ing with the individual. This sensation does not appear when the skin is hot or the temperature high. The contraction of ves- sels in the skin may cause cerebral congestion if cold is not ap- plied to the head before beginning the pack. The body tem- perature is lowered. The patient may be nervous and excited for the first few minutes. The vasomotor and heat-regulating centers are stimulated to combat the cold. The "tonic reaction" LOCAL AND GENERAL APPLICATIONS OF COLD 391 follows with stimulation of all the vital processes of the body resulting in the improved function of every organ and stimula- tion of the heat-producing processes in the muscles, glands and digestive tract. The heat produced is expended to warm the cold sheet and evaporate its moisture. If the treatment is discon- tinued at this point, that is, after the reaction has begun, its effect will be tonic and alterative. This treatment is used as a tonic in all forms of wasting dis- eases and in chronic toxemia. A cold pack may be given to reduce body temperature and relieve toxemia. This form of treatment is frequently used in fevers and is especially useful in typhoid fever as a substitute for the Brandt bath. To produce the above effect, when reaction sets in, that is, as soon as the application is warm, it should be renewed in one of the following methods: (1) The wet sheet may be changed every five to ten minutes, as the case demands, with vigorous rubbing applied with each renewal and dry blankets wrapped around the patient; (2) The sheet may be sprinkled with cold water, the patient being turned from side to side so that the fresh applica- tion is made to the whole body. A sprinkler or whisk broom may be used, the sheet being kept continuously wet. Fric- tion is applied throughout. The duration may be ten minutes. The temperature varies from 60 to 65° F., 70 to 80° F., or 85° F. II. The Neutral Stage or the Sedative Pack.—This stage sets in as soon as sufficient heat is accumulated to raise the tempera- ture of the pack to that of the body surface, that is about 98° F. If the pack is discontinued at this point or if further accumula- tion of heat is prevented, a sedative effect follows. The patient becomes quiet, calm and usually goes to sleep; the pulse and respirations are slowed; the kidneys are stimulated so that more urine is secreted. This treatment is used as a therapeutic measure in chorea, in insomnia and the delirium of typhoid or pneumonia etc.; in acute mania and in all forms of cerebral irritation. III. The Heating or Exciting Stage.—When the heat is allowed to accumulate still further, reaching beyond the temperature of 98°, all the excitant effects of the hot bath (see page 362) appear. Cold applications to the head, therefore, must be con- stant and frequently renewed and the pulse must be watched carefully. If heat elimination, through perspiration, does not promptly set in, then all the depressing and exhausting effects of the prolonged hot bath occur. IV. The Sweating and Exciting Stage.—As the heat still further accumulates, the body temperature is elevated, the heat-elimi- native processes are stimulated, perspiration becomes profuse and all the exciting and stimulating effects of the hot bath appear. This treatment may be used in all cases where it is desired to increase the elimination of toxins and waste products. 392 THE PRINCIPLES AND PRACTICE OF NURSING Contraindications.— (1) In skin diseases; (2) in advanced cardiac or Bright's disease; (3) in febrile conditions. Contraindications to the Cold Pack.— (1) In eruptions of the skin; (2) in asthma; (3) for those who, for any reason, cannot react without friction or other mechanical means because, in a cold pack, the body is left entirely to its own resources except in the method used to reduce body temperature and toxemia. Method of Procedure.—Preparation of the Patient.—The pa- tient is usually placed between blankets as in giving a hot pack. Before beginning the treatment the whole surface of the body, especially the feet, must be warm. Cold applications are applied to the head. Method of Applying the wet sheet.—The sheet to be applied is usually wrung out of water at from 60° to 70° F. It must be wrung very dry. When applied, it must be wrapped smoothly, closely and snugly around the body so that no two surfaces of the body are in contact with each other. The sheet must be in such close contact with the whole body surface that no pockets of air remain. Such pockets of air would allow conduction and evaporation of heat, thus chilling small areas. This chilly sen- sation would gradually extend to the whole surface, delay the reaction, and cause great discomfort. When chilly sensations are prolonged, it is usually due to improper applications. Folds should be made in the sheet at the neck and shoulders so that it will fit snugly but not too tightly. If the feet do not react well they are left out of the wet sheet. This is frequently necessary. One or both arms may be left out if the patient does not react well. The blankets are wrapped smoothly and carefully around the body, fitted tightly and snugly at the neck in order to pre- vent any evaporation. They are pulled in such a way as to bring all the wrappings in close contact with the body surface. The blankets are so tucked in that the patient now looks like a mummy. A towel is arranged to protect the skin of the face and neck from the blankets. A large rubber may be wrapped around the patient and hot-water bottles placed at the feet or along the sides, if necessary, to further prevent evaporation of heat or to hasten the reaction. Duration of the Pack.—The pack should end when the desired effect has been obtained. The tonic effect is usually attained in about twenty minutes, but is determined by the patient's sensa- tions. A feeling of warmth and comfort indicates that reaction has set in and the desired effect is attained. The sedative effect is usually attained in about one hour. The patient should be removed from the pack at this time, but, if asleep and previously very restless, the sedative effect may be prolonged, without disturbing the patient, by preventing the further accumulation of heat. The rubber and blankets should be loosened and the wrappings gradually removed. Great care must be taken to prevent local currents of air or chilling the patient in any way. On removal from the pack the patient LOCAL AND GENERAL APPLICATIONS OF COLD 393 should be dried with a warm towel, using as little friction as pos- sible. The patient's gown should be warm. For the eliminative effect the pack usually lasts about two hours, or as long as sweating continues without exhaustion. It must not be too prolonged. Symptoms of nervousness, headache, fainting or vertigo indicate overstimulation which may be inju- rious if allowed to continue. The after-treatment is the same as in the hot pack. THE BRANDT BATH This is the cold tub bath used in the treatment of typhoid fever. It consists in the complete immersion of the body in a bath at 95° to 85° F. or at 85° to 70° F. for from ten to twenty minutes. Some doctors prefer to use the bath at the higher tem- peratures given, believing that the results are better and that the shock, excitement, alarm and resistance of the patient to the extreme low temperature may do harm. The bath is accom- panied by friction to the whole body surface throughout the treatment. Effects of the Bath.—The nerve centers are stimulated and restored; vital resistance is increased; muscle tone, the activities of the kidneys, liver and skin are all increased. The amount of oxygen received and of carbon dioxid eliminated is nearly three times the normal amount, showing a marked increase of oxida- tion in the body. Blood-pressure is increased, the pulse is slowed, the heart is strengthened and stimulated and the number of blood corpuscles, especially the white cells, is increased. The cold bath is used in typhoid fever for the following reasons: 1. To regulate and increase the movement of blood through the blood vessels, thereby preventing or relieving visceral congestion and resulting loss of function. 2. To stimulate the nerve centers and relieve them of the toxins which depress vital activities and cause headache, de- lirium, insomnia, stupor or coma, etc. 3. To relieve congestion and increase the activity of the liver so that it can destroy the toxins brought to it from the intestines and so protect the whole system. 4. To improve the circulation of the kidneys, thereby prevent- ing nephritis and increasing the elimination of toxins. The volume of urine may be greatly increased. 5. To improve the circulation, the nutrition and the function of the skin and so increase the elimination of heat and waste products and prevent bedsores. 6. To stimulate respirations. 7. To increase oxidation, including that of toxins so aiding in their destruction and elimination. 8. To increase the flow of digestive juices, the absorption and 394 THE PRINCIPLES AND PRACTICE OF NURSING assimilation of food thereby improving the appetite, and the nutrition and function of every body cell. 9. To improve the quality of the blood and increase the num- ber of red and white blood cells. In typhoid the white cell count is low. 10. To build up vital resistance and cause the destruction and elimination of toxins from bacteria and tissues. 11. To tone up the muscles of the heart and blood vessels and prevent failure due to toxins. 12. To lower the body temperature and to make the patient more comfortable. 13. To prevent complications—bedsores, intestinal hemorrhage, perforation, pneumonia or nephritis. The typhoid tub bath is usually given every three or four hours when the temperature is 102° or 103°, not because the lowering of the temperature is the primary object, but because the tem- perature runs parallel with and is a definite, easily determined indicator of the increased toxicity of the body. The patient dies from the effects of toxins in the body, and not from the increased temperature. In fact, the increased temperature is now believed to be a defensive reaction on the part of the body—an effort to destroy and to repel the germs which cannot live in a higher temperature. However, this reaction too, like an inflammatory reaction, though purposeful and beneficial, may go beyond the point of safety and defeat its own purpose so that it, too, must be regu- lated. For, it has been found that an internal temperature (always two or three degrees higher than that registered in the axilla) of 107.6° to 109.4° will destroy the white blood cells, and further lower the resistance by causing a rapid wasting of mus- cular and other tissues of the body. The typhoid tub bath, therefore, aims to destroy and elimi- nate the toxins and prevent or relieve their poisonous effects on the body. It is contraindicated in 1. Infancy, old age or inability to react. 2. Shivering, sweating, a subnormal temperature or collapse. 3. Threatened intestinal hemorrhage or perforation. 4. The presence of blood in the urine. 5. In skin diseases, pneumonia, nephritis, and other acute in- flammatory conditions. Method of Procedure.—Strict typhoid precautions must be observed throughout the treatment. Preparation of the Patient.—The patient is covered with a sheet. The upper bedclothes are removed or fanned to the foot of the bed. The patient's gown is removed and his loins are draped. The canvas usually used for liftjng and supporting the patient in the tub is then put carefully under him. The poles, used for lifting, are then inserted in the canvas. He should be disturbed as little as possible and prevented from exerting him- LOCAL AND GENERAL APPLICATIONS OF COLD 395 self in any way. Non-absorbent cotton may be placed in the ears to avoid the accidental entrance of cold water, as this may cause earache, headache, dizziness and nausea. Cold applications are applied to the head and face, the temperature of the appli- cation being much lower than that of the bath. Preparation of the Bath and Method of Giving:—Before the patient is prepared the necessary articles and utensils are brought to the bedside. The tub is filled about two-thirds with water at the required temperature, and is brought to the bedside. Two people lift the patient on the stretcher very carefully, but as quickly as possible, from the bed into the water. The sheet covering the patient is not removed until after he is in the bath. No exposure should be allowed. The patient must be immersed to the neck, care being taken not to leave the shoulders uncovered as this would allow evaporation and cause chilling and possibly pneumonia. The head is supported with a rubber pillow or air- ring. The sheet is then removed. The patient must be in a comfortable position and supported so as to avoid all strain or exertion. During the bath friction is applied throughout the whole treat- ment. Friction is not applied to the abdomen. Hair on the chest, if long and plentiful, should be cut short, because the rubbing and bathing make the hair follicles red, swollen and painful. The cold applications on the head should be changed frequently and their temperature kept constantly lower than that of the bath. The patient will shiver and complain of chilliness at first. If he continues to shiver, if his teeth chatter and his skin becomes cyanotic, stop the treatment. Remove him at once from the bath, cover him with a sheet and blanket and rub until reaction sets in. A patient is not, as a rule, removed from the bath because he complains of chilliness unless his teeth chatter. Treatments are not as a rule discontinued because of chilliness, but the doc- tor may order whiskey or may raise the temperature or shorten the duration of the bath, or friction may be increased. The patient's pulse should be watched carefully. He should be watched closely for symptoms of chill or cyanosis, and for symp- toms of hemorrhage or perforation on account of moving the patient. The duration of the bath is usually ten minutes unless other- wise ordered. While the patient is in the bath, his bed may be completely remade or the linen may be tightened and freshened, then covered with a large rubber. When the bath is completed, the patient is again covered with the sheet and the loin draping is removed. Two people, as be- fore, carefully lift the stretcher and the patient and hold it over the tub to allow the water to drain off before placing it on the bed. The cold applications are then removed from the head and the patient is dried with the sheet. As the patient is turned from side to side, the wet rubber and canvas may be removed and the 396 THE PRINCIPLES AND PRACTICE OF NURSING back dried and rubbed with alcohol and talcum. The patient's gown, the pillows and bedclothes are replaced and the damp sheet removed. The patient's temperature is usually taken one hour after the bath. Some doctors prefer, however, that the patient, if sleep- ing, should not be disturbed for this purpose as a natural sleep is one of the effects for which the bath is given. A nurse should find out from the doctor what his wishes are in this respect. Sleep must not be confused with a toxic condition of stupor. In this condition, taking the temperature will not disturb the patient. When charting the treatment, its general effect and the way in which the patient reacted should be noted. THE COLD WET HAND RUB This treatment consists in rubbing the whole surface of the body with the cold wet hand. The effects are those resulting from cold applications com- bined with the mechanical effects of friction. As the application is made and reaction produced in different parts of the body in succession, no marked retrostasis with internal congestion occurs as in the tub bath, while its tonic and stimulating effects are gradually produced. The treatment is used in febrile conditions where the cold tub bath is too vigorous a treatment. The temperature varies from 40° to 75° or from 65° to 90° F. according to the age of the patient and his ability to react. The duration is usually about ten minutes, the application be- ing made and reaction secured in each part as quickly as pos- sible. When the duration is ten minutes, three minutes should be devoted to the anterior surface and seven minutes to the pos- terior for the following reasons: (Hare) (1) The great muscles and the thick skin of the back retain the heat; (2) the posterior parts, the skin and viscera are more apt to be congested and need the stimulating effect of the cold application and rubbing, in order to prevent the skin from breaking down and in order to stimulate the function of both the skin and internal organs such as the kidneys and lungs, etc Method of Procedure.—Preparation of the Patient.—Before beginning the treatment everything likely to be required should be brought to the bedside. The patient is covered with a large sheet. The clothes are fanned to the foot of the bed, the pillows and gown are removed; the loins are draped and a large warmed rubber which may be covered with a sheet is placed under the patient to protect the bed. The body must be warm before the treatment is given in order to secure a prompt reaction. Brief friction should first be applied to stimulate the skin, prevent chilling, and to hasten the reaction. A hot-water bottle may be placed at the feet to encourage the reaction and for comfort. Cold applications are applied to the head. LOCAL AND GENERAL APPLICATIONS OF COLD 397 During'the treatment, the upper sheet may be removed, or it may remain and only the parts under treatment be exposed in succession, then covered as reaction sets in. The treatment may be given without any exposure. Reaction must be produced by rubbing. If possible, two nurses should give the treatment, one applying water with her hands and rubbing the face, anterior surface of the trunk and upper extremity, while the second nurse treats the lower extremities. This should last three minutes. The patient is then turned and the posterior surfaces treated, beginning with the neck, shoulders, chest, etc., with special atten- tion to the spine. This lasts seven minutes. During the treatment it is important to watch the patient's color and pulse. Sometimes one-half ounce of whiskey is given if the patient's color and pulse are poor. It is not used as exten- sively as formerly, as it is now believed to depress nerve centers and weaken the action of the heart muscles. Many believe that it does not stimulate and therefore does not aid in securing a reaction. When the treatment is completed, the patient is covered with the sheet and dried gently, using very little friction. The rub- ber, etc., is removed, a warm gown is put on, and the pillows and bedding, etc, are arranged to the comfort of the patient. In charting, the patient's temperature and reaction to the treatment are charted as after a cold tub-bath. THE COLD SPONGE BATH This treatment consists in the application of cold water to the body surface by means of a wet sponge, combined with friction or rubbing with the hands. The effects of the bath are the same as in the wet hand rub, but as more water is usually used, more heat is lost, and the reaction is more intense. Its uses, the underlying principles, and method of procedure, are also the same. As it is a more vigorous treatment special care should be taken to see that the surface is warm before begin- ning, that the feet are warm throughout, and that a marked reaction is produced, the pulse and color of the patient being carefully watched. THE SPRAY OR SLUSH BATH When it is desirable to use still more water, extra protection for the bed is provided. This is arranged so as to provide a trough, and the head of the bed is elevated so that the water will drain into a receptacle on the floor at the foot of the bed. The water is either sprayed or poured from a pitcher over the body, thus adding the mechanical stimulus of slight percussion. CHAPTER XXV NURSING PROCEDURES USED IN THE TREATMENT OF INFLAMMATION AND CONGESTION AND OTHER CONDITIONS (Continued) DOUCHES AND MISCELLANEOUS BATHS HOT AND COLD DOUCHES A douche consists of a single or multiple column of water directed against some portion of the body. Physiological effects.—-By the application of the douche all the thermal effects due to applications of either heat or cold are hastened and intensified by the mechanical effects of the pres- sure or force and volume of water used. The effects depend upon the following factors: 1. The temperature of the water used. This varies from 45° to 125° F. 2. The pressure, which varies from ten to sixty pounds. 3. The duration varies from three or four seconds to four or five minutes, depending upon the temperature, pressure and other factors in the application. The neutral or sedative douche at a temperature of 92° F. and with very low pressure is sometimes prolonged to fifteen minutes. 4. The form of the stream is determined by the outlet. The horizontal, vertical, fan, or broken jets may be used. The form may be the shower, spray or needle bath applied to the surface of the body and irrigations to various cavities of the body such as the eye, ear, nose, throat, stomach, rectum, colon, bladder, vagina or uterus. 5. The area covered, which may be local or general. 6. The part of the body to receive the application, if local, as in the dorsal, lumbar and spinal douches. Purposes of the douche: The douche, either as a local or general application, may be used to produce tonic, stimulating, sedative or analgesic effects as desired. It is contraindicated in acute inflammation, and in very nerv- ous, excitable patients where it is necessary to suppress reac- tion due to the application. As the effects of the douche depend entirely upon the scientific regulation of the above mentioned factors and as these factors can only be accurately administered by a very highly trained 398 DOUCHES AND MISCELLANEOUS BATHS 399 person and by specially constructed apparatus, no attempt will be made here to discuss the various applications. A special room is also necessary. The use of the apparatus and the method of procedure can only be taught by practical demonstrations. Ex- cept in special hospitals, nurses are not, as a rule, trained or required to give special treatments. A spinal douche, however, may be given fairly successfully either in the hospital or in a private home, and so may be prescribed by the doctor. SPINAL DOUCHE In the spinal douche a stream of water is moved rapidly up and down over an area covering the whole surface of the spine and extending three or four inches on either side of it. The effects of the treatment vary according to the tempera- ture, pressure and duration of the application. When special apparatus is not available it is difficult to obtain the exact tem- perature desired and impossible to secure the desired pressure. When desirable, friction may be used as a mechanical substitute for pressure. A tonic effect may be obtained by a cold spinal douche. The temperature may vary from 45° to 78° or 80° F. The duration may be for three or four seconds. A sedative effect may be obtained by a tepid (80° to 92° F.) or a neutral (92° to 97° F.) douche. The duration may be three or four minutes. An analgesic effect may be obtained by a hot douche. The temperature varies from 104° to 125° F. The duration may be from one-half to four or five minutes. The temperature should begin at 100° F. and gradually in- crease to the maximum. As a hot douche is usually given to relieve pain, a low pressure is always used and the stream must be rapidly moved from point to point to prevent burning. The high temperature mentioned may be used because the skin of the back is not as sensitive as in other parts of the body. The Scotch Douche.—The spinal douche may be given in the form of a Scotch douche in which a single application of hot water is followed immediately by a single application of cold water. The hot douche lasts from one to four minutes, and the cold douche from three to thirty seconds. The purpose of the hot douche is to warm the part in order to intensify the effect of the cold, and to secure a better reaction. It also trains the patient to react to the cold douche and makes it feel grateful. The cold douche must follow the hot instantly as any lapse allows the wet surface to cool off rapidly by evapo- ration. The purpose of the hot application would then be lost. The Alternate Douche.—When the spinal douche is given in this form, hot and cold applications are repeatedly applied in alternation. The duration of each application is usually about fifteen seconds. 400 THE PRINCIPLES AND PRACTICE OF NURSING Method of Procedure.—When the treatment is given to the patient in bed, the preparation of the patient and bed is the same as in a spray or slush bath. The patient should lie prone or on his side. Only the back should be exposed. A hot-water bottle may be placed at the feet, if necessary, as they must be warm. The body should also be warm. Friction may be applied before, during and after the treatment, if necessary, to obtain the reac- tion. Cold applications may be applied to the head. When the patient is able to get out of bed, he is covered with a large sheet or bath blanket and is allowed to sit on a board placed across the foot of a bath tub. He may sit on a box or stool placed in the tub. This is especially advisable to avoid an accident and injury when the treatment is given for chorea in which the jerky, uncertain and uncontrollable movements of the patient make it impossible for him to sit without support. His back should be toward the faucets. The sheet or blanket is then draped so as to completely cover the body, leaving the back only exposed. The feet should rest on a stool or should be placed in a foot-tub of water at from 100° to 110° F. In a very hot douche this is necessary to prevent burning and in a cold douche to secure reaction. To give the douche a spray is attached to the faucet and the stream is moved rapidly up and down over the prescribed area. When a hot douche is used great care must be taken to avoid burning the patient. A nurse should test the temperature of the water by directing it against her arm. When the treatment is completed the care of the patient is the same as after a sponge or spray bath. THE AFFUSION The affusion, like the douche, is a stream of water directed against the body. Unlike the douche, it has little mechanical effect and is applied to a larger area of the body. It may be a local or general application, the water being poured over the part from a pitcher or a pail. The Effects of the Affusion.—The usual thermal and circu- latory reactions follow according to the temperature used. The treatment is used as a therapeutic measure in syncope, collapse, or shock, in asphyxia, in fevers and in hypostatic con- gestion. In private practice it is sometimes used instead of the douche. It is contraindicated in typhoid fever with complications, in hemorrhagic cases, and in patients with a decompensating heart. MISCELLANEOUS BATHS These are baths in which various substances are added to the water, which, according to the ingredients used, either increase its irritating and stimulating effect, or lessen and soothe irritation. DOUCHES AND MISCELLANEOUS BATHS 401 THE EFFERVESCENT OR NAUHEIM BATH "This consists of a full bath the water of which contains chlo- rid of calcium, carbonate of soda, and carbonic acid gas." It is an artificially prepared bath used as a substitute for the natu- ral mineral water of the famous resort of Nauheim, Germany. The effects are the same and depend upon the proportion of chemical substances used. Composition of the Bath.—The following ingredients are put up in powder form so that one, two or three powders may be used according to the intensity of the effect desired. Sodium carbonate D/2 pounds bicarbonate xfa " Calcium chlorid 3 " Sodium chlorid 2 " " bisulphate 1 " Effects of the Bath.—These chemical irritants added to the neutral bath produce a powerful circulatory reaction—that is, dilatation of the cutaneous blood vessels, with contraction of the adjoining and associated visceral vessels—without provoking a thermic reaction. The disadvantages of using extremes of tem- perature, in certain cases, may thus be avoided. The bath is used in cardiac and renal diseases where extremes of temperature are undesirable or dangerous. Method of Procedure.—The tub should be lined with rubber to prevent injury to it due to the chemical ingredients. The Nauheim baths are very exhausting and therefore only to be used with the greatest caution. If dyspnea is present the patient must not enter the bath; the breathing must be quiet and tranquil. The chest should be wet before entering, and the limbs well rubbed during the bath. No exertion must be allowed either during or after the bath. The baths are carefully graded to suit the patient as regards the strength of the ingredients used, the temperature and the duration of the bath. They should begin with the mildest ingred- ients, at 95° F., should last only two or three minutes, and should be given only every other day. Even the strongest must not take more than three baths in succession without a clay's interval. The patient must not be allowed to become chilled before, dur- ing or after the bath. After the bath the patient should be wrapped in a hot sheet, and given friction until dry. He should then be allowed to rest for an hour or two. SALINE BATHS These are artificially prepared sea-water baths. Composition of the Bath.—Eight pounds of sea-salt to thirty gallons of water, or by using five to eight pounds of ordinary salt, practically the same effects may be produced. For partial baths use four ounces to one quart. 402 THE PRINCIPLES AND PRACTICE OF NURSING The temperature of the bath is usually 70° F. The duration is usually ten minutes with friction during and after the bath. Effects of the Bath.—Sea-water feels much warmer than fresh water because the salts present irritate or stimulate the nerves in the skin and so hasten the reaction, or the increased flow of blood in the skin and the feeling of warmth and comfort. This makes it possible to give the saline bath two or three degrees lower than that of the fresh water bath usually tolerated by the patient, so that both the desired circulatory reaction and the tonic effects of the thermic reaction are produced. The usual precautions are taken to avoid chilling or exhaustion. After the bath the patient should be wrapped in a warm sheet and brisk friction applied. THE MUSTARD BATH In the mustard bath, mustard is added as a chemical irritant to hasten the reaction and stimulate the circulation in the cutan- eous blood vessels. It is used as a stimulating bath particularly for infants and young children to restore vitality. It is frequently used in convulsions in infants to relax the muscles and relieve the spasm, due to its stimulating effect on the nervous system. Composition of the Bath.—One tablespoonful of mustard is used to one gallon of water. Half this strength is used for a mustard-bath for infants. The mustard must be mixed in the usual way into a paste with tepid water, then further dissolved and thoroughly stirred into the bath water. The temperature must be suited to the patient's condition, but may be lower than when water alone is used. It is usually 80° to 90° F. if the full effect of the mustard is desired. When the temperature is from 105° to 110° F., the mustard helps at first by hastening the desired reaction, but the effect of the mustard is soon destroyed by the heat. (See Chapter XVI.) ALKALINE BATHS These are artificially prepared baths used as substitutes for natural mineral springs which owe their soothing effects to the alkaline ingredients present. Composition of the Bath.—Four to twelve ounces of carbonate of soda to thirty gallons of water; or one-half ounce of carbonate of soda to the quart for local applications; or eight ounces of bicarbonate of soda to one gallon of water are used. Alkaline baths are most commonly used in various skin dis- eases and in jaundice and urticaria to relieve itching. EMOLLIENT BATHS These consist of the usual neutral tub bath to which some emollient substance has been added. DOUCHES AND MISCELLANEOUS BATHS 403 The composition of the bath may be four to six pounds of bran to thirty gallons of water. The bran is boiled in a bag for twenty minutes, the water is then drained off and added to the bath. One pound of corn starch to thirty gallons of water may also be used. The starch is first mixed into a smooth paste with cold water. Hot water is then slowly added (stirring constantly), until the mixture is thin enough to pour. It is then added and mixed thoroughly with the bath. The temperature of the bath is usually from 93° to 96° F. The bath is used to relieve skin irritations of various forms. THE SULPHUR BATH Sulphur is an insecticide, and is very injurious to lower forms of vegetable life. It is used extensively in the form of an oint- ment and occasionally in the form of a bath in acne and in vari- ous skin diseases in which parasitic organisms are present such as scabies. To prepare the bath, dissolve from one-half to two ounces of potassa sulphurata (sulphurated potash) in a small amount of hot water and add the solution to the bath-water (15 gallons). The temperature of the bath usually varies from 90° to 96° F. The duration varies from ten to thirty minutes. The bath tub should be protected as sulphur is injurious to metals. It must be thoroughly disinfected after use when the bath is given to relieve infectious skin diseases. Method of giving the Bath.—When the alkaline, emollient, or sulphur baths are given to relieve irritations of the skin, the patient should be allowed to lie quietly in the bath for the dura- tion ordered. No friction should be applied during or after the bath. When the bath is completed the patient should be wrapped in a warm sheet and dried by gently patting over the sheet. THE ALCOHOL SPONGE BATH The alcohol sponge bath is given as a cooling, refreshing meas- ure when you wish to disturb the patient as little as possible by turning or moving. Alcohol evaporates and cools the surface quickly so that only a small amount of alcohol is needed and the patient is less tired out than in the more prolonged water sponge bath. The composition of the bath is usually one part of alcohol to three parts of water at any temperature desired. The bath is used as a cooling measure to reduce fever, and to relieve the night sweats of phthisis. Method of Procedure.—The bath is given like the cold sponge bath already described with the exception that as only a small amount of alcohol is used and as the chief purpose may be to avoid turning or moving the patient, no rubbers are used to pro- tect the bed. Bath towels are placed at either side of the patient 404 THE PRINCIPLES AND PRACTICE OF NURSING and under the legs. The sponge should be only slightly wet. The back should be rubbed with the hand moistened with alcohol instead of with the sponge and, if advisable, without turning the patient. Sometimes the alcohol sponge is preceded by a warm bath in order to bring the blood to the surface and increase the evaporation of heat when the alcohol is used. If given with care the bed should not become dampened. CHAPTER XXVI NURSING PROCEDURES USED IN THE TREATMENT OF DISEASES OF THE ALIMENTARY TRACT The treatments commonly used are gastric lavage, gavage, test meals and expression of the stomach contents for purposes of examination as an aid to diagnosis. GASTRIC LAVAGE A lavage is a method of washing out the stomach. Lavage is a French word derived from the Latin lavare "to wash," and is used to express the washing out of a hollow organ. Conditions in which a Lavage is most Commonly Used:— 1. In acute gastric catarrh due to irritant, toxic, decomposing substances, corrosive poisons or alcohol, etc. In this condition the contents of the stomach show an increased secretion of mucus and a lessened secretion of hydrochloric acid, pepsin and ren- nin. 2. In chronic gastritis in which the stomach may be enlarged or atrophied with lessened motor power and secretions. The return may show quantities of thick, brown, tenacious mucus which may form a thick scum on the water. 3. In gastric carcinoma in which there is usually a lessened amount or a total absence of hydrochloric acid. This condition prevents digestion, causes stagnation, prevents the opening of the pyloric valve, permits the growth of bacteria and fermentation with the production of gases, acids and dilatation of the stomach. There may be the appearance of blood or of "coffee ground" vomitus. This is due to the presence of partly digested blood, that is, blood in which the hemoglobin has been broken up by the gastric juice and the hematin set free. Hematin is a brown pigment which gives to the contents its "coffee ground" ap- pearance. 4. In persistent vomiting. 5. In some cases of intestinal obstruction with fecal vomiting due to the retroperistalsis in the intestine and regurgitation of its irritating contents through the pyloric valve into the stomach. 6. In some cases of gastric ulcer but here lavage is usually con- traindicated. 7. Sometimes following operations, before the patient is con- scious, to thoroughly wash out the stomach and free it from ether, and bile, etc., so as to prevent later discomfort, nausea and vomiting. 405 406 THE PRINCIPLES AND PRACTICE OF NURSING 8. In dilatation of the stomach which may be (a) Acute—following a general anesthesia or injuries to the head and spine, etc. (b) Chronic—due to pyloric stenosis or obstruction from any cause. It may be due to strictures, or carcinoma in the stomach or external to the stomach but causing pressure on the pylorus; or it may be due to motor insufficiency or loss of muscular tone which may be the result of chronic gastritis, general debility or anemia, etc (c) The result of distention when the stomach is constantly filled to excess as in beer drinkers or in diabetic patients whose tissues are unable to assimilate the food (sugar) and who are therefore unsatisfied and ravenously hungry. The normal limit or capacity of the stomach is from 1500 c.c. to 1700 c.c, but there are cases in which the stomach has been found to contain 120 ounces. The dilatation is chiefly in the cardiac portion. In any case where fermentation is marked the peristaltic wave is observ- able over the organ and the splashing of the contents may be felt on palpation or heard on auscultation. Marsh gas is said to be one of the gases formed as a result of fermentation and, during eructations of this gas, it is stated that it may be ignited at the mouth. A lavage may be given for the following reasons: 1. To cleanse the stomach of undigested food, fermenting ma- terial, gases, toxic and poisonous substances or mucus. Mucus in the return from the diseased stomach—thick, brownish and tenacious—must be distinguished from mucus from the throat which is thin, abundant and transparent. The stomach is usually washed out before a meal because even a small amount of the sour fermenting substance, left in the stomach between meals will contain bacteria and will be suf- ficient to reinfect each meal as it enters the stomach resulting in fermentation with the formation of gases and acids and a great deal of distress and pain after meals. 2. To cleanse, give comfort and prolong life in carcinoma. 3. To stimulate peristalsis and the secretions in the stomach. The repeated distention and emptying of this muscular organ is said to act as local gymnastics stimulating and strengthening it. In nervous pains it may act as a warm sedative douche. 4. To check hemorrhage. A very hot or very cold solution is used with great caution. It is contraindicated (or should be given with great caution) in:—1. Ulceration with hemorrhage or following a recent and very severe hemorrhage from the stomach due to ulcer or car- cinoma, etc. 2. Uncompensated heart disease. 3. Aneurysm of the thoracic aorta. 4. Advanced pulmonary tuberculosis. 5. Apoplexy. 6. Cirrhosis of the liver causing obstruction of the portal cir- GASTRIC LAVAGE, GAVAGE AND TEST MEALS 407 culation with varicose gastric veins which predispose to hemor- rhage. The blood supply to the walls of the stomach is very free and the blood vessels freely anastomose so that a hemor- rhage from a gastric ulcer or other cause may be very severe. 7. Advanced arteriosclerosis. 8. The habitual use is injurious and should be avoided. Method of Procedure.—In giving a lavage the following arti- cles will be necessary: a dressing rubber and draw sheet to protect the patient and the bed; a kidney basin in case the patient vomits; gauze handkerchiefs to wipe away the mucus, etc., and to cleanse the tube; a paper bag for the soiled handkerchiefs; a large pitcher containing the solution; a small pitcher for pouring; a pail for the return and a basin containing the stomach tube in cold water or ice. (A rubber catheter is used in giving a lavage to an infant.) This hardens the rubber, makes its passage easier and makes the taste and feeling less disagreeable to the patient. No lubricant is necessary or desirable as any lubricant is dis- agreeable to the taste and increases the tendency to nausea and the normal mucus in the throat is usually a sufficient lubricant. This mucus is also increased when the tube is being passed. The tube used should be smooth and flexible, about 4.5 to 5 feet long, of medium size, but large enough to allow for the return of semi- solids without clogging. Otherwise only the fluid will be carried off, leaving a more irritating fermenting mass behind. The end of the tube should be closed and rounded. The holes should be large and at the side, not at the end, in order to avoid the direct force of the application against an irritated surface such as an ulcer and to prevent direct suction in the return should the hole be in contact with an ulcerated area, as this would predis- pose to a hemorrhage. No pump should be attached to the ordi- nary stomach tube, as its use, by suction, may injure the coats of the stomach. In exceptional cases a pump is used to create a vacuum and produce suction to aid in the return, but it should always be used with great caution. The solution may be plain water or water containing salt or bicarbonate of soda (.*> i to a quart) which softens and dissolves the mucus. In cases of poisoning a solution of potassium per- manganate, tannic acid, or silver nitrate may be used. The temperature may be from 100° to 106° when used for cleansing. It may be tested by pouring the solution over the back of the hand as differences of one or two degrees have little effect. The quantity may be from two to six quarts, depending upon the condition. When given for cleansing the treatment is con- tinued until the return is clear. The physical and mental condition of the patient.—Before be- ginning the treatment it is important to know the patient's mental condition and attitude, his physical condition, the diagnosis of the disease, the purpose for which the treatment is given, and whether it is given for the first time or not. If the patient has 408 THE PRINCIPLES AND PRACTICE OF NURSING had previous treatments there will be no difficulty, but if it is an entirely new experience there will be difficulty in passing the tube and considerable distress and discomfort to the patient. Reassure the patient about the total absence of danger, the cer- tain great relief which will follow, and the fact that the discom- fort, which is greatly lessened by lack of resistance, is only temporary. Explain that at first there may be gagging and vomiting, and a choking sensation, but that there will be no dif- ficulty in breathing when the tube is once inserted properly. The insertion of the tube will be greatly aided if the patient swal- lows continually. The patient will probably struggle and invari- ably becomes cyanosed, but this is due to the choking and struggling and not to the tube having entered the larynx, which is possible under certain conditions, but not at all probable. If the patient is very nervous or irrational, assistance will be necessary and a mouth gag should be used to prevent the patient from biting the tube. When given for dilatation, with accumulation of pent-up fluid and gases, etc, special care should be taken to protect the bed, etc., and to quickly invert the funnel and keep it directed down- ward when passing the tube, in order to allow the escape of the fluid, etc, into the pail. When the stomach is full the cardiac sphincter is closed, and the accumulation is largely in this cardiac portion. The gases being lighter will be at the top, so when the stomach is relieved, the gases and fluid are released and expelled with considerable force and the result may be disastrous to the appearance of the nurse and the surroundings. Also, when the patient has been vomiting, it is wise to invert the funnel, after passage of the tube, to siphon back the contents before introducing the solution. In this way considerable fluid is frequently obtained, the patient is made more comfortable and is relaxed, so that the treatment is given more easily and with better results. In carcinoma and gastric ulcer the nurse must be on the lookout for pain and for blood in the return. Discontinue the treatment if there is blood in the return. Again in all cases but particularly when the patient is known to be weak, watch the patient for pallor, a flagging pulse and other signs of exhaustion. The time and.frequency of the treatments vary, but they should not be given within from five to six hours after a meal. While food normally begins to leave the stomach in one-half hour, it is not normally completely emptied in less than from four to six hours. The purpose of the treatment is to remove contents which are irritating, which the stomach cannot expel in the normal time, which interfere with its function and if allowed to remain will ferment and sour the next meal eaten. A lavage is some- times necessary two or three times a week or may be necessarv every day. It is best given before breakfast so that the stomach will be in the best condition to digest the food given. The position of the patient should be comfortable and free from strain. The treatment may be given with the patient lying GASTRIC LAVAGE, GAVAGE AND TEST MEALS 409 down, but is best given with the patient sitting up. The rubber and sheet are arranged so as to protect the patient and the bed. Before passing the tube, remove any false teeth or a plate which the patient may have. Remove all air from the tube by squeezing it between the fingers. The tube must be empty when inserted so that in this treatment air is not expelled by passing water through the tube, on account of the danger and possibility of water trickling into the trachea. The introduction of air into the stomach will cause pain and flatulence and will also inter- fere with siphonage. It is not necessary to lubricate the tube (except when it is soft and recoils on itself or when the tissues are inflamed or ulcerated), as the mucus in the throat is suf- ficient and any lubricant tends to cause nausea. Occasionally it is necessary to paint sensitive parts with cocain but the patient soon becomes accustomed to the treatment. Ask the patient to hold the head slightly forward. Holding the head back makes the act of swallowing, and therefore the pas- sage of the tube, difficult. Pass the tube along the curve of the hard and soft palate into the pharynx and esophagus but avoid touching the back of the pharynx, if possible, as this causes gag- ging. Normally the upper end of the esophagus is closed; this prevents the entrance of air into the stomach. Ask the patient to take deep breaths, to breathe slowly with the mouth open, to say a-a, then to swallow continually if possible. This flattens the tongue and opens the esophagus and starts the contractions of its muscles which carry the tube downward. When the tube enters the esophagus there may be a muscular spasm. Never try to force a passage, as this only increases the spasm. Stop, ask the patient to breathe more slowly and deeply, then if the patient swallows, the spasm relaxes. There are two other constricted portions of the esophagus which may make the passage difficult, —one a little below the opening, the other where the muscles of the diaphragm form a sort of sphincter around it, as it passes through the diaphragm. If the patient simply keeps on swallow- ing, the tube will pass without difficulty. The length of the tube to insert varies with the patient. The esophagus begins at the sixth cervical vertebra and its lower end passes through the diaphragm opposite the tenth thoracic verte- bra, to enter the stomach opposite the eleventh thoracic. In the adult the average length of the esophagus is about ten inches and the distance from the teeth to its opening is about six inches, making the distance from the teeth to the entrance of the stomach 15% to 16 inches. The average length of the tube inserted is about 18 inches. The stomach tube is quite large so that normally there is little danger of passing it through the small and carefully guarded opening into the sensitive larynx. However, where the muscles are relaxed or paralyzed, or when the nerve endings are stunned and fail to give warning or when the patient is unconscious and the brain asleep so that the warning comes in vain, it is possible 410 THE PRINCIPLES AND PRACTICE OF NURSING then for the tube to enter the larynx. Therefore note the color and breathing of the patient; if the patient becomes cyanotic, if a hissing sound is heard instead of a gurgling sound, or if air can be felt when the funnel is held against the cheek, do not pour the water into the funnel as the tube is probably in the larynx and the water would enter the lungs and drown the patient. Remove the tube. If the patient is breathing naturally and does not become cyanosed, it is safe to proceed. When the stomach tube is in place, quickly fill the funnel; allow the water to run through, but before the funnel or tube is entirely empty refill it to prevent air from being drawn in. Never allow the tube to become empty, as this causes a very painful, dragging sensation in the stomach. Allow the fluid to run in slowly, never with force. When two or three funnelfuls have been introduced, and before all the water has run through the tube, pinch the tube and invert the funnel over the pail and allow the fluid to siphon back. If you allow all the fluid to enter the stomach, leaving the tube empty, it will be difficult or im- possible to obtain any siphonage. Never introduce more than one pint without siphonage for in dilatation of the stomach large quantities may be retained causing increased discomfort and a resulting paralysis of the walls of the stomach. Continue the treatment until the return is clear unless there is pain or blood in the return or the patient shows signs of exhaustion; then dis- continue and report the condition to the doctor. When the treatment is given for the first time, the patient may vomit, the vomitus returning around the tube. If vomiting con- tinues, it is usually advisable to remove the tube and to reinsert it after vomiting has ceased. Use gauze to cleanse the secretions and vomitus from around the mouth. Sometimes the return from the lavage comes back around instead of through the tube. This may be because the tube is clogged with a semi-solid substance or filled with air. When clogged, pouring in another funnel of water may dislodge the substance, or it may be necessary to re- move the tube and cleanse it. To expel air, pinch the tube and squeeze through the fingers in order to create a vacuum and obtain suction. It may also be because the tube is not in the stomach; the tendency of the stomach is to expel it. When there is difficulty in obtaining the return or the flow stops it may help to move the tube up or down slightly or to pour in more fluid until the patient complains of a sense of fulness. When a nurse is giving the treatment, however, it is safest to pour in only one extra funnelful. When the treatment is completed, pinch the tube tightly in front of the teeth (using gauze or the drawsheet)' and withdraw it quickly to prevent food or fluid entering the larynx. Return the tube to the basin. Cleanse the patient's mouth and face; remove the draping and make the patient comfortable. Remove and cleanse the utensils. A mouth-wash, particularly if the pa- tient has been vomiting, will be very refreshing. GASTRIC LAVAGE, GAVAGE AND TEST MEALS 411 In charting, chart the amount and character of the vomitus (if any), the amount of flatulence, the quantity and quality of mucus, the color and any abnormality in the return and the amount of water used before the return became clear. The Care of the Stomach Tube.—When used for one patient only, the stomach tube need not be boiled after use as frequent boiling softens and renders it useless. It should be cleansed in- side and out with cold water then with warm water and soap. If hung up to drain, spread the tube over a towel and do not allow it to bend at a sharp angle as this will cause the rubber to crack when dry. When the same tube is used for other patients it should be boiled for from one to three minutes both for cleanliness and for esthetic reasons. A GAVAGE Gavage is a French word derived from gaver, which means to gorge fowls, and is therefore used to indicate forced feeding through a tube. It is a method of introducing liquid food or medicine into the stomach through a stomach tube for patients who cannot, or will not swallow food. It is indicated in the following conditions: 1. In some operations on the jaw or tongue. 2. In insanity, when the patient refuses food and is in danger of starving. It is also given to fasting or hunger-striking pris- oners for the same reason. 3. Where the feedings the patient is able to take are inade- quate. 4. In strictures or spasms of the esophagus when the patient cannot swallow food. 5. In conditions in which patients are unconscious. 6. In tetanus. 7. In poisoning, to introduce an antidote for the poison. The necessary articles will be the same as for a lavage with the exception of the flask containing the nourishment and as all the fluid is to be retained no pail will be required. The temperature of the fluid should be about 105° F. It should always be tested to avoid the danger of burning the patient. The tube is introduced in the same way as for a lavage. The stomach will probably try to get rid of it by contraction of its muscular walls at first, so before introducing the fluid, wait a few moments until the peristalsis or unrest has subsided. Allow the fluid to flow in slowly, and with no force so as not to excite peristalsis. Before all the liquid has left the funnel and tubing, pinch the tube and withdraw gently but quickly in order to pre- vent air from entering and also to prevent the entrance of fluid into the trachea. After the treatment the patient should be left comfortable, quiet, and undisturbed, so as to avoid the expulsion of the nourishment. 412 THE PRINCIPLES AND PRACTICE OF NURSING A NASAL GAVAGE In this method of feeding, liquid food is introduced into the stomach through a rubber catheter which is passed through the anterior and posterior nares and the pharynx into the esophagus. When forced feeding is necessary this method is less exhausting. It is indicated (1) when a patient is in a weakened condition and cannot swallow food; (2) sometimes in operations on the mouth, such as carcinoma of the tongue, a cleft palate or frac- ture of the jaw, etc.; (3) in operations on the throat and some- times after a tracheotomy; (4) in tetanus or meningitis with a locked jaw; (5) in forced feeding for irritable or violent patients; (6) in very weak infants. The articles required will be a medium sized rubber catheter and a small glass funnel attached, in a basin of cold water, a lubricant, a flask containing the nourishment, cut gauze, a paper bag, dressing rubber and drawsheet. The position of the patient may be lying down with the head turned to one side or sitting up with the head tilted forward. An infant should lie across the knees with its head turned away from the nurse. The catheter should be inserted in the uppermost nostril. The food may consist of any liquid food which will readily pass through the tube. The temperature of the liquid should be warm not hot. The lining of the nose is much more sensitive than that of the mouth and the danger of burning the patient is greater when feeding by this method. Method of Procedure.—When inserting the catheter direct it toward the septum of the nose. First lubricate it. If there is difficulty in passing the tube remove it and insert it in the other nostril. The septum of the nose is frequently deviated or de- flected, making the chambers of the nose unequal in size. The tube should reach into the esophagus, so pass all the tube with the exception of a few inches which are necessary in manipulat- ing the funnel. As the catheter is small there is considerable danger of its passing into the larynx, therefore when introduced observe the patient's color and breathing before pouring in the solution, which would drown the patient if the tube should be in the larynx. Even a small amount of food in the lungs, besides being the cause of severe irritation and dyspnea, if allowed to remain (that is, if not coughed up), would decompose and probably lead to a lung abscess or septic pneumonia. If the tube is in the trachea a whistling sound will be heard when the funnel is held to the ear, while if in the esophagus probably a gurgling sound. As the tube is soft it may become coiled upon itself in the mouth or in the throat. If the fluid is poured in while the tube is in this position it will cause gagging, choking and gasping, and will almost certainly enter the larynx causing dyspnea, cyanosis GASTRIC LAVAGE, GAVAGE AND TEST MEALS 413 and later a possible abscess and septic pneumonia. Look in the mouth or pass the finger to the back of the throat to see if the tube is in position. Before pouring in the solution, wait until the parts are at rest, until all distress has subsided and normal breathing is estab- lished and to make sure that the tube is in the esophagus. Then as a further precaution pour in only a few drops at first, then pour the balance in very slowly if there are no symptoms of choking. After all the fluid has left the funnel, pinch the catheter and quickly withdraw. THE EXPRESSION OR SIPHONAGE OF THE STOMACH CONTENTS The expression of the stomach contents consists in their with- drawal, by siphonage, through a stomach tube. An examination of the return is usually made for diagnostic purposes. The ex- pression frequently follows the ingestion of a "test meal" after a suitable time. The test meal is given when the stomach is fasting. This method of examination is used in the diagnosis of 'sus- pected diseases of the stomach such as (1) gastritis; (2) gastric ulcer; (3) gastric carcinoma; (4) dilatation; (5) hypersecretion and hyposecretion of gastric juice; (6) hypermotility and hypo- motility (increased or decreased motor power or activity of the muscular walls). These tests indicate (1) the motor power of the stomach; (2) the secretory activity and the rate and amount of digestion; (3) the absorptive activity. The motor activity is the ability of the stomach to pass its contents into the small intestine in the normal time. It depends upon the condition of the food ingested, the tone of its muscular walls, and whether or not there is an obstruction at the pylorus. Normally after a full meal food begins to leave the stomach in half an hour, and in from four to seven hours all the food will have left the stomach. The Secretory Activity.—Normally gastric juice is secreted only in response to some food stimulus. The secretion may be stimu- lated by (1) a psychical stimulus—the thought, odor or sight of food; (2) the tasting and chewing of food, particularly if pala- table; (3) a hormone, or chemical messenger, in the saliva which, by the blood stream, reaches the stomach before the food, and, as it were, announces the coming meal and orders a supply of gastric juice; (4) the saliva itself, swallowed with the food may act as a stimulus and (5) some think the chief stimulus is the contact of the food with the mucous lining of the stomach. Prob- ably all these factors contribute but with the test meal the last factor is most important. The amount of gastric juice secreted is about 2000 c.c. per day. 414 THE PRINCIPLES AND PRACTICE OF NURSING It is highly acid, containing hydrochloric acid (0.1 to 0.3 per cent.), salts, and the enzymes pepsin, rennin and lipase, but little solid matter. Mucus is also secreted by the mucous lining. The function of the hydrochloric acid is: 1. To inhibit the growth of bacteria and neutralize the saliva. 2. To combine with the protein and make it possible for the pepsin to act. 3. (Free hydrochloric acid.) To close and keep up the tone of the cardiac sphincter, to open the pyloric valve and, when in the intestines, to close the pyloric valve and stimulate the secretion of the intestinal juices. It will thus be seen that if there is a lessened amount or an absence of hydrochloric acid, no digestion of protein (the chief work of the stomach) can take place; the pyloric valve will not open; the undigested food will accumulate; bacteria will develop unchecked; fermentation and decomposition of the contents will result forming gases and organic acids; the stomach will dilate; the cardiac sphincter will lose its tone and eructations of gas and sour contents (heart burn) will occur. The amount of free hydrochloric acid in the return is therefore a very important in- dication. The pepsin changes the acidified protein to proteoses and pep- tones. The rennin in the presence of calcium salts changes the casein (protein of milk) into a soft curd so that the pepsin can more easily digest it. The enzyme lipase may digest to a limited extent fats already emulsified, but it is believed that this enzyme is destroyed by the percentage of acidity present in the normal stomach. COMMON TEST MEALS I. The Ewald test meal is usually used for the routine test. It consists of a roll or slice of bread without butter, a glass of water or a cup of weak tea without sugar or cream. In giving any test meal instruct the patient to chew the bread or other solid food very thoroughly, otherwise coarse particles may re- main undigested and be too large to enter the tube, or they may enter and plug it. The meal is given on a fasting stomach (usu- ally early in the morning) and is expressed one hour later. Much may be learned by observation of the return, and this the nurse should carefully note and chart. The macroscopic examination reveals.—1. The amount and character of the return. The normal amount (at the end of one hour) is from 20 to 50 c.c. of gastric contents. If there is little or no return, the result indicates hypermotility. The same re- sult may occur in an hour-glass stomach. At the end of two hours no trace of the meal should be left. If 200 to 300 c.c. of gastric contents are obtained, the result indi- cates a diminished motility or a hypersecretion of gastric juice. GASTRIC LAVAGE, GAVAGE AND TEST MEALS 415 The contents may be undigested portions of the test meal, fluid and food partially digested, such as fruit skins, which have re- mained for some time in the stomach. Sometimes 500 c.c. up to three or four quarts are obtained. This points to diminished motility and dilatation, usually resulting from a benign or malig- nant obstruction of the pylorus. With hypermotility there may be no food. In severe chronic gastritis little or no digestion may have taken place and there will be a great deal of mucus, usually dark brown and tenacious. 2. The color may indicate the presence of blood, either bright red (a fresh hemorrhage) or "coffee ground," that is, mixed with the contents and giving it a "coffee ground" appearance due to an old hemorrhage and showing partial digestion of the blood. A greenish tint shows the presence of bile. 3. The odor.—Normally after a test meal the contents have merely a slight acid odor. A fecal odor points to the presence of regurgitated fecal matter and may indicate intestinal ob- struction. If the contents have a very sour odor it indicates the presence of acetic (sour odor) and butyric acids (putrid odor), which result from fermentation of stagnant contents in a dilated stomach. A very foul odor of putrefying flesh is sometimes present in carcinoma due to putrefaction and death of tissue. A microscopical examination of such material will reveal the presence of mucus, fat, starch, pus, yeasts, bacteria, blood, elastic or muscle fibers, and carcinoma cells, etc. The chemical analysis is to test (1) the reaction of the con- tents; (2) the amount of free hydrochloric acid. Normally the stomach secretes hydrochloric acid until a sufficient amount has combined with the food and continues to secrete until the free or uncombined acid reaches about 0.2 per cent. This is the most important test as the work of the stomach depends upon this acid and it is the ingredient usually increased or diminished. Normally after the Ewald test meal the average amount of free hydrochloric acid is 30 to 40 c.c, that is, based on the amount of alkali necessary to neutralize 100 c.c. of gastric contents, it would normally take 40 c.c. of alkali. In disease (hypersecre- tion) this may reach 80 to 90 c.c; (3) the estimation of the combined hydrochloric acid, that is, the amount combined with the food. This varies greatly, but the average is from 10 to 15 c.c. (50 grams of bread will combine with 0.15 grams of acid); (4) the total acidity, which includes not only the useful and nec- essary hydrochloric acid, but also organic acids, such as lactic, acetic and butyric, which were either taken in with the food or resulted from fermentation in the stomach. In vomitus it is the presence of these acids which gives the very sour odor and which makes the mouth and lips, etc., of the patient so sore. Acetic and butyric acids are fatty acids (butyric acid is present in rancid butter). They indicate stagnation of contents with fermenta- tion and an absence of hydrochloric acid which, if present, would 416 THE PRINCIPLES AND PRACTICE OF NURSING check the bacteria which produce fermentation. These acids, although they provide an acid medium, aid digestion very little, if any, and even seem to interfere. The total acidity, then, may be high even in the absence of hydrochloric acid. It varies greatly; in health it may be 50 to 80 c.c In disease it may be much higher (hyperchlorhydria) or it may be very low as is frequent in carcinoma. Further analysis will indicate the pres- ence and activity of pepsin, rennin and lipase as indicated by the digestion of proteins and fats. Hydrochloric acid is usually decreased (hypochlorhydria) in chronic gastritis, dilatation and acute infectious diseases. Hydrochloric acid may be absent (achlorhydria) in advanced chronic gastritis, in carcinoma and in pernicious anemia. Hydrochloric acid is usually increased (hyperchlorhydria) in gastric ulcer. After the Ewald test meal the food is not allowed to remain in the stomach long enough to test the rate and amount of digestion. II. The Riegel Test Meal consists of a plate of plain meat broth, 200 grams of tender beefsteak, 150 grams of finely mashed potatoes or two slices of white bread (or a roll), and a glass of water. Instruct the patient to chew this very thoroughly. The meal may be removed in from three to six hours. The advan- tage of this meal over the Ewald meal is that it is a normal meal, is more palatable and therefore stimulates a more normal gastric secretion due both to the pleasurable psychic effect (which is absent or even accompanied by an inhibitory effect in the Ewald meal), and also to the contact of the food with the lining of the stomach. It enables the doctor to tell how long food remains in the stomach after a normal meal, and also, as it is allowed to remain for several hours, to judge the rate and amount of digestion. If at the end of three hours, when the stomach tube is passed, no return is obtained, the motility is either normal or increased. If after four hours a large amount still remains and the food is undigested the motility is decreased and the digestive power is very poor. A chemical and microscopical analysis may also be made as in the Ewald test meal. III. The Fasting Stomach Test.—Sometimes to test the motility of the stomach in dilatation or pyloric obstruction, the stomach tube is passed seven to eight hours after the last meal (when the stomach should be completely empty), to find out if any food is still retained. Again, all the stomach contents may be removed by a thorough washing (lavage) and the patient given food difficult to digest (such as raisins or fruit cake con- taining currants), and easily recognizable if not thoroughly di- gested,—these may be obtained in the siphonage days after. IV. The Salol Test is also used to test the motility of the stomach. It is based upon the fact that salol is only broken up into its constituents, phenol and salicylic acid, by the in- GASTRIC LAVAGE, GAVAGE AND TEST MEALS 417 testinal juices. The salicylic acid is absorbed by the intestines and eliminated in the urine. One gram of salol in a capsule is given the patient after a meal and the bladder is emptied. If the motility of the stomach is normal or is not decreased, salicylic acid should appear in the "urine in one to one and a half hours. V. To test the absorptive power of the stomach, 15 grains of potassium iodid are given and the saliva is tested with a starch paste to detect the presence of iodin, which colors the starch blue. There is little, if any, absorption of food in the stomach, but some drugs, such as alcohol, iodin, etc., are absorbed. Iodin is eliminated in the saliva, which explains why patients receiving potassium iodid constantly complain of the disagree- able taste in their mouths, even though the taste of the drug may have been disguised in its administration. Normally, in six to ten minutes the starch paste turns a violet color, and in fifteen minutes a deep blue color indicates the presence of iodin in the saliva. Method of Procedure.—The articles required to express the stomach contents will be the same as for a lavage with the ex- ception that no solution will be required and a special receptacle for the return will be necessary. To obtain the best results, if possible have the patient sitting up, with the head tilted slightly forward and the mouth slightly opened. The position must be natural and easy to facilitate swallowing of the tube. Insert the tube as for a lavage, taking all the preliminary precautions to explain the treatment and to reassure the patient. The greatest patience, consideration and skill will be required as the results depend upon it. There must be no haste or excitement. If the tube is not passed successfully on the first trial, allow the patient to rest a moment and recover, then try again, but do not tire the patient out. When the tube is inserted sometimes there is difficulty in ob- taining the return. Siphonage may be aided by pushing the tube in a little further or by pulling it out slightly. Ask the patient to cough, to lean forward and "bear down," to make pressure over the region of the stomach or to strain as in vomit- ing or at stool. This causes depression of the diaphragm (with pressure on the stomach), a closure of the glottis and a contrac- tion of the abdominal muscles (with pressure on the stomach). This is Nature's way of emptying the stomach in vomiting—a closure of the glottis, contraction of the diaphragm and abdom- inal muscles, causing forcible pressure on the stomach. If these measures are unsuccessful the contents will have to be removed by aspiration. This is accomplished by creating a slight vacuum by squeezing a rubber bulb in the tubing or by attaching a Politzer bag to the tube and creating suction. As the test for the acidity of the contents expressed is the most important factor from a diagnostic standpoint, it is essen- tial that the saliva from the mouth (which is alkaline and greatly increased by the passage of the tube) should not become mixed 418 THE PRINCIPLES AND PRACTICE OF NURSING with the return, as it would neutralize the acid and render the test useless. To prevent this wrap a towel around the tube so that it will absorb the saliva as it runs from the mouth. When withdrawing the tube ask the patient to cough again so as to force the remains of the meal or gastric juice into the stomach tube. Then compress the tube so that none may be lost and rapidly but gently remove it. Keep the tube compressed until all the return is transferred to the special receptacle for it. The stomach contents must be carefully covered and sent to the laboratory immediately. It must be kept on ice until ex- amined to prevent further action of the enzymes, fermentation, putrefaction, or any alteration in the contents. This would ren- der the analysis useless or would lead to very faulty conclusions. In charting the procedure, note the amount, character, odor and color of the return. Note also that a specimen was sent to the laboratory for examination. Summary of the Results.—Ulcer.—The presence of blood and free hydrochloric acid is very suggestive. Dilatation.—The retention of food for 24-48 hours; vomiting large amounts; diminished hydrochloric acid; organic acids present, and bacteria are suggestive. Carcinoma.—Diminished motility and hydrochloric acid; the presence of bacteria, yeasts, blood, organic acids and tumor cells are suggestive. Chronic Gastritis.—Increased mucus and diminished ferments suggest chronic gastritis. Hypersecretion.—Increased gastric juice in a fasting stomach; increased hydrochloric acid after test meals are suggestive. CHAPTER XXVII THE ADMINISTRATION OF MEDICINES The administration of medicines is one of the most responsible duties assigned to student nurses. As a rule, such responsibilities (except the giving of simple, relatively harmless remedies) are not given a student until she has had instruction in materia medica and medical diseases, and has had considerable expe- rience in the observation and care of patients. Without such knowledge and experience it is not safe for even the most con- scientious student to administer drugs, the purpose and effects of which she is ignorant of. This duty is therefore only assigned to an experienced nurse trained to understand the dangers and responsibility involved. The responsibilities of the nurse are to see that the medica- tions are received by the patients accurately, promptly and in such a way as to give the best results. In order to do so intelli- gently she should consider the nature of the drug, its action, local and systemic, in the body, to what its action is due, the maximum and minimum dosage, the factors which modify the dosage and its effect, the disease from which the patient is suf- fering, the effect desired, why the drug is being given, and the symptoms which indicate the desired and possible undesired re- sults. She should also know and watch for symptoms of over- dosage because (a) some people show an idiosyncrasy and sus- ceptibility to certain drugs, (b) some drugs are very slowly excreted and when continued may cause cumulative poisoning, (c) some drugs are "pushed to their physiologic limit," that is, until the first symptoms of overdosage appear. She should also know the treatment for poisoning by the va- rious potent drugs. To be familiar with the habit-forming drugs and the necessity for, and the means of restricting their use are also important responsibilities of the nurse. To give drugs—all of which are more or less undesirable, many of them highly injurious and poisonous, the last remedy to be considered by modern doctors and used as sparingly as possible —in any other way is a dangerous procedure. No nurse should dare to be ignorant, disinterested or mechanical in the adminis- tration of drugs. As with other practical procedures, the class- room should not be relied upon by the student for the study of pharmacology and the administration of medicines. The ward 419 420 THE PRINCIPLES AND PRACTICE OF NURSING is the ideal place where each drug can be studied in relation to the individual patient and disease. Accuracy, Punctuality and Efficiency.—To insure that the right patient is given the right medicine at the right time, each hospital has developed or adopted a definite system for the administration of medicines which usually includes the following: The Doctor's Order-Book.—On each ward there is usually a book in which all the doctor's orders are written. Except in extreme emergencies no medication should be given a patient unless the order is written in this book (a nurse may write the order dictated) and signed by the doctor. When an emergency prevents this the order should be written and signed later. All orders must be clearly written. A nurse should never give a medication if in doubt as to the drug or dosage. When a nurse goes to the operating-room for a patient she should take this order-book with her so that orders may be written and signed there. Sometimes there is a separate order-book for day and night, but in any case the date, and whether the medications are ordered during the day or night should be clearly indicated. Nurses should look at this book frequently because a doctor may write an order without calling the attention of a nurse to it and the patient may be suffering for want of the medication. When a medication ordered is not to be repeated, when given it should be marked off with red ink indicating the time when given. The order and the time are copied on the chart. If such an order is not marked off the drug may be given a second time and en- danger the life of the patient. Those which are to be repeated are marked off when the order is transferred to the medication tickets or cards used for convenience and accuracy in administra- tion. Colored tickets (2 inches square) are commonly used, each color indicating the time of administration as in the following: Color of Ticket Time of Administration Plain yellow Every four hours Yellow with corners cut Four times a day Plain pink Three times a day Pink with corners cut Every three hours Orange Before meals Orange, % ticket Every night Blue After meals Pale orange Twice a day Red Every six hours Red, V2 ticket Every morning White Every two hours Green When required Medications to be given by hypodermic injection must be designated on the ticket. When this system is used the orders should be transferred from THE ADMINISTRATION OF MEDICINES 421 the order-book to the tickets by the headnurse or, if by a pupil nurse, checked by the headnurse. The patient's name and the medication must be clearly written. The tickets must be kept clean and legible. They should be safely locked in the medicine cupboard. The headnurse should have a record by means of which she can daily check the number of medications given at different hours. When a medication is altered or discontinued the ticket is placed on the desk and destroyed by the headnurse. The headnurse should daily check the order-book, the medica- tion tickets and the patient's charts to see that all agree. The tickets should be arranged in packets according to the colors or time of administration. When the medications are to be given out, the nurse places the tickets in a row and, as the medication is prepared, attaches the ticket to the glass and does not remove it until the medicine is given to the patient. The tickets should then be placed on the headnurse's desk to indicate that the medications have been given. Abbreviations.—In writing orders or medication tickets and in charting, abbreviations are always used so that a nurse must become familiar with the following: Preparations of Drugs Abbreviation Derivation Meaning Aq. aqua water aq. dest. aqua destillata distilled water Comp. compositum compound Conf. confectio confection Dil. dilutus dilute Empl. emplastrum plaster Fl. fluidum fluid Inf. infusum infusion Lin. linimentum liniment Liq. liquor liquid Lot. lotio lotion Mist. mistura mixture 01. oleum oil Pil. pilula pill Pulv. pulvis a powder S. fr. spiritus frumenti whisky Sp. spiritus spirit S. v. r. spiritus vini rectificatus alcohol S.v.g. spiritus vini gallici brandy Syr. syrupus syrup Tinct. tinctura tincture Troch. trochiscum lozenge Ung. unguentum ointment Vin. vinum wine 422 THE PRINCIPLES AND PRACTICE OF NURSING Directions for Dosage and Application Abbreviation Derivation Meaning aa ana of each Add. adde add to Add. part. dol. adde partem dolente to the painful part ad. lib. ad libitum as much as desired C. congius gallon C. centigrade c. cum with C. c. cubic centimeter Cap. capiat let him take Contin. continuatur let it be continued Dim. dimidius one-half D. in p. aeq. dividatur in partes aequales divide in equal parts Div. dividatus divide Dur. dolor. durante dolore while the pain lasts Ft. fiat let it or them be made Gm. gram, grams gr. grain, grains gtt. drop, drops Garg. gargarisma a gargle M. misce mix M. minim N.b. nota bene note well No. numero number 0. octarius a pint Part. vie. partibus vicibus in divided doses Q.s. quantum sufficit as much as is sufficient 3 recipe take s. sine without S. or Sig. signa give the following direc tions S.o.s. si opus sit if necessary Ss semi one-half 3. drachma dram 1- uncia ounce 9. scrupulum a scruple Directions for Time of Administration. Abbreviation Derivation Meaning A.c ante cibum before meals Alt. die. alternis diebus alternate days Alt. hor. alternis horis alternate hours Alt. noct. alternis noctes alternate nights Am. morning B.i.d. bis in die twice a day THE ADMINISTRATION OF MEDICINES 423 Directions for Time of Administration. Abbreviation Derivation Meaning H. hora hour H.d. hora decubitus at bedtime H.s. hora somni at sleeping time Min. minute M. et N. mane et nocte morning and night O.d. omne die daily O.m. omne mane each morning O.n. omne nocte each night P.c post cibum after meals P.r.n. pro. re nata when required Q.h. quaqua hora every hour Q.2h., Q.3h. every two, three or four Q.4h. hours Q.i.d. or 4 i.d. quater in die four times a day Stat. statim at once T.i.d. ter in die three times a day Hours of Administration 4.i.d. 8 a.m., 12 n., 4 p.m., and 8 p.rr q. 2 h. 6, 8, 10, 12, etc. q. 3 h. 9, 12, 3, 6, etc. q. 4 h. 8, 12, 4, etc q. 6 h. 6, 12, etc. B. i.d. 10 a.m., 4 p.m. T.i.d. 10 a.m., 3 p.m. and 6 p.m. A.c i/^-hour before meals—6:30 a.m., 12:30 p.m., 4:30 p.m. P.C. 8 a.m., 2 p.m., 6 p.m. O.d. 10 a.m. O.m. 6 a.m. O.n. 8 p.m. The Medicine Chest.—Accuracy, punctuality and efficiency are greatly facilitated by a property arranged medicine cupboard. If possible, it should be near the ward and near running water. It should always be locked, the key properly tagged and kept in a safe place, to which only nurses and doctors have access. The cupboard should be divided into compartments with ample shelf spacing. Solutions, ointments, liniments, etc., for external use should be in separate compartments. Substances for in- ternal use should also be in separate compartments; solids and liquids are kept separately; poisons should be kept separately and should be in bottles differentiated by color, roughened sur- face or shape and clearly marked poison; all potent drugs such as morphin, strychnin, etc., usually given hypodermatically, should be in a separate compartment; as far as possible drugs used for a similar action should be grouped together—cathartics, 424 THE PRINCIPLES AND PRACTICE OF NURSING respiratory preparations, sedatives, etc. Oils should be kept in a cool place—they are decomposed by heat and made rancid by exposure to air. Sera and vaccines are kept in the ice box. The cupboard should be well supplied with all the drugs likely to be required, but it should never be overstocked. Its contents should be examined daily. Day nurses should see that there is suffi- cient for the needs of the day and should be particularly watchful to see that the necessary supply is provided for the night. Drugs should be ordered in small amounts as many deteriorate or lose their effect if not fresh. Any change in color, odor or con- sistency should be reported. Bottles should be securely corked and labelled. Labels should be printed and always clean. No nurse, however, should ever alter or change the labels—this should be done by the pharmacist only. To avoid soiling the label, when pouring the solution from the bottle the label should be held uppermost. The rim of the bottle should always be cleansed afterwards. Medicine should never be. left in a glass or bottle unmarked. If a drug has two names, commonly used, it is wise to have both names printed on the label. The dose of potent medicines is sometimes printed on labels. Cupboards, shelves, bottles, labels, etc., should be immaculately clean and orderly. Bottles should be of a uniform size and shape, not crowded, and arranged so that each label is clearly visible. To avoid overcrowding and confusion, prescriptions ordered for special patients, if discontinued or if the patient is discharged, should be returned to the drug room. Method of Administration.—The physician prescribes the medication, the dosage, the time of administration and the chan- nel through which it is to be given. Like all other treatments, however, the effects of the medication will depend upon the in- telligence, accuracy and care with which it is prepared and administered to the patient. Factors Modifying the Dosage and Effects of Drugs.—A nurse is not responsible for the dose ordered but she is held re- sponsible for seeing that by no possible error will the patient re- ceive an amount which he is not intended to have. For this rea- son, she should know the maximum and minimum dosage of the various preparations of drugs likely to be ordered and the factors which modify the dosage and effect upon the patient. Some of these factors are: 1. Age.—As it is impossible to learn the dosage for all ages, various rules have been formed for estimating the dose for a child from the adult dose. The rules are usually based on the age and weight. Young's rule, which is one commonly used is, ace Adult dose X---zr^o Sucn mles ^° not always»apply because age -\- 14 children react differently to different kinds of drugs. For in- stance, "children react strongly to opium and other narcotics, while on the contrary, the child's dose of a cathartic or bella- THE ADMINISTRATION OF MEDICINES 425 donna or arsenic approaches that of an adult. In old age, the dose of drugs which are weakening or depressing, such as irri- tant cathartics or narcotics, is smaller than the usual adult dose." 2. Sex.—The adult dose is based upon the average weight of a man. As women weigh less than men, the dose ordered is often smaller. 3. Previous Habits or Toleration.—When a patient has been in the habit of taking drugs such as morphin or alcohol it is often dangerous to stop the use of the drug suddenly. When given, larger doses are necessary to produce any effect. For instance, following an accident or in pneumonia, when the patient has been in the habit of drinking, whisky will be administered to prevent delirium tremens. If morphin is given in the same conditions to relieve pain or to quiet the patient and produce sleep, larger amounts will be necessary if the patient has been in the habit of taking morphin. Patients quickly develop a tolerance for all sedative drugs. 4. Idiosyncrasy and Susceptibility.—Certain foods and drugs, which may be given to most people with safety, produce in others very unusual and poisonous effects. For instance, some people have a decided intolerance for cocain or opium so that even small doses of these drugs produce toxic symptoms. 5. Temperament and Occupation.—Patients of a neurotic temperament and easily excited are more susceptible than those who are stolid or of a phlegmatic temperament. Patients whose habits have been sedentary are more apt to be susceptible than those hardened by an active out-door life. 6. Condition of the Patient.-—When pain is great, large doses of morphin may be ordered. When the patient's breathing is already difficult, smaller doses of morphin will be given and the patient will be closely watched for further depression of the respiratory center. In shock or collapse the dosage of stimu- lants ordered may be larger than usual. When drugs are given as an antidote for poisoning large doses are ordered. On the other hand, in diseases of the kidneys or in any disease with edema smaller doses may be ordered and at greater intervals. Failure of the kidneys to eliminate the drug will cause it to accumulate in the body with poisonous results. In edema the drug may be dissolved and accumulate in the excess fluid and as the fluid is eliminated, large amounts of the drug may be suddenly dumped on the tissues with poisonous results. In such diseases the nurse should watch the patient closely for symptoms of cumulative poisoning. 7. Nature and Form of the Medication.—The effect of some drugs, such as ammonia, nitrites and adrenalin, wears off very quickly so that they are given more frequently. Other drugs, such as digitalis, are absorbed and eliminated slowly so that they are given less frequently in order to avoid cumulative poisoning. Medications in liquid form or well dissolved are absorbed and 426 THE PRINCIPLES AND PRACTICE OF NURSING act more rapidly than when in solid form. For this reason when pills or tablets, etc., are given, plenty of water should also be given to help dissolve them and to aid in swallowing. When pills, etc., are not fresh they should be crushed into a powder to be sure that they will be properly dissolved. Urotropin should always be crushed into a powder and well dissolved in a medicine glass of water. The antiseptic effect of urotropin is due to the formaldehyde contained in it. The drug must be thoroughly dissolved and broken up in order to liberate the formaldehyde. All powders are best dissolved in water. For this reason, many doctors object to having bicarbonate of soda given in a capsule. It should be dissolved in a medicine glass of water. When powders will not dissolve in water they should be allowed to float on water in a glass or spoon or placed on the back of the tongue and washed down with a glass of water. 8. Object of the Medication.—A large dose of ipecac acts as an emetic whereas a small dose acts as an expectorant. 9. Time of Administration.—The effect of drugs is much more marked when given on an empty stomach. For instance, alcohol on an empty stomach may intoxicate, but when taken during or after a meal may aid in digestion but produce no systemic effects. Larger doses of drugs are, therefore, usually necessary after meals to produce the effect desired. 10. The Channel of Administration.—The dose varies with the rapidity with which it is absorbed. For instance, when given intravenously the dose is small because the full effect of the drug is felt immediately. When given by rectum the dose or- dered may be larger than when given by mouth because it is felt that the rate and amount of absorption is generally less rapid and certain. To insure accuracy in the administration of drugs, when pre- paring and giving medications, a nurse must concentrate on what she is doing and allow no conversation or interruption of any kind. She should read each ticket carefully, think about the nature of the drug, the condition of the patient, the desired effect and how best to obtain it. The label on the bottle should be read three times—before taking the bottle from the shelf, before pouring out the medicine and before returning the bottle to the shelf. Immediately place the corresponding ticket with the glass. This careful check in reading the labels is essential. Fail- ure to do so has led to fatal results. The nurse, only, should give the medication to the patient and she should remain with the patient to see that it is taken. Always use the proper ap- paratus for measuring or weighing—use graduated glasses for measuring ounces or drams, a minim glass for minims, and a pipette or medicine dropper for drops. Never give drops for minims or vice versa. When measuring fluids hold the graduate so that the eye is on a level with the line indicating the desired quantity. Measure the exact amount ordered. Never pour a medicine back into a bottle. Always shake the bottle before THE ADMINISTRATION OF MEDICINES 427 pouring the medicine, particularly when there is a precipitate. Medicines which, when mixed, change color or form a precipitate should not be given at the same time without reporting this fact to the doctor. They are said to be incompatible, due to the chemical reaction which occurs when they are mixed. All medi- cines should be given promptly at the time ordered. Channels of Administration.—Medications may be adminis- tered by one of the following channels:— I. Intravenously. II. By inhalation. III. By hypodermoclysis. IV. By intramuscular injection. V. Subcutaneously. VI. By mouth. VII. By rectum. VIII. By inunction. The channel by which medications are administered depends upon the effects desired, the rapidity of action necessary, the nature and amount of the drug to be given and the condition of the patient. The desired effect may be a direct local effect, a systemic effect, or a remote local effect. For instance, bicarbonate of soda is given for a direct local effect when given to neutralize acid in the stomach, and for a systemic effect when given to neutralize acids in the blood, as in acidosis. Opium is given for a direct local effect when given by rectum to relieve pain as in hemorrhoids. It may also be given by rectum to produce a sedative effect on the whole system through its action on the nervous system. Ipecac (a large dose) is given for a direct local effect on the stomach when given to cause vomiting, but for a remote local effect when a small dose is given as an expectorant. In the latter case the drug is absorbed and eliminated partially through the respiratory system. Urotropin, given as a urinary antisep- tic, is another example of a drug given by mouth for a remote local effect. Drugs given for a systemic, or remote local effect, must be absorbed into the general circulation. According to the rapidity with which the action is desired, the nature and amount of the drug to be given, and the condition of the patient, drugs are given by one of the following channels: I. Intravenously.—When an immediate action is desired the drug may be given directly into a vein. It may be dissolved in a small amount of normal saline solution and given by intravenous injection or added to a large amount of normal saline or other isotonic solution and given by intravenous infusion. For the method of giving an intravenous infusion, see Chapter XXXII. Salvarsan and neosalvarsan are drugs usually given intraven- ously. Salvarsan and Neosalvarsan.—Salvarsan (arsphenamine) and neosalvarsan (neoarsphenamine) are preparations of arsenic used 428 THE PRINCIPLES AND PRACTICE OF NURSING chiefly in the treatment of syphilis. Salvarsan is also used m sleeping sickness, relapsing fever, malaria, pernicious anemia, leukemia and other diseases. Salvarsan is also used as an aid to diagnosis in suspected syphilis when the Wassermann tests have been negative. Fol- lowing the injection, if the condition is syphilitic, the Wasser- mann test may be positive. When used in this way it is called a "provocative dosage." It is thought that the above preparations indirectly destroy the spirochsete pallida causing syphilis and not directly, as was at one time thought, by combining with and destroying the proto- plasm of the organism. Salvarsan is commonly called 606, because this number repre- sents its place in the series of compounds prepared by Ehrlich as neosalvarsan is represented by 914. The dosage of salvarsan varies from 0.2 gramme (3 grains) to 0.6 gramme (10 grains) depending upon the age, sex, and general health of the patient, and the character of the disease. The dosage of neosalvarsan varies from 0.15 gm. to 1.5 gm. They are given.at intervals varying from four days to two weeks, com- monly one week. Method of Administration.—The drugs are sometimes given intramuscularly or subcutaneously, but more frequently, intra- venously. Salvarsan is a diacid solution and before use must be made into a sterile solution of slightly alkaline or neutral reaction. A 15 per cent, solution of sodium hydroxid is added for this purpose. The dose (0.6 gm.) is dissolved in a small amount of sterile normal saline solution to which 23 drops of the sodium hydroxid solution are added. To this, sterile normal saline solution is added, making 300 c.c. in all. The injection may be given with the same apparatus and should be given with the same aseptic precautions as in giving a transfusion or intravenous injection. The preparation of the patient and precautions used in injecting the solution are the same. Plain normal saline may be injected first to insure that the needle is properly inserted in the vein (so that it will not enter the tissues with resulting irritation and inflammation), and after the injection to be sure that none is left in the vein. Neosalvarsan may be administered with much greater ease as it readily dissolves in water and is already of neutral reaction. The drug is dissolved in freshly distilled warm sterile water (sometimes in normal saline solution). The preparation of the patient is the same as above. The only articles necessary for the injection are a sterile glass to mix the solution, a large glass syringe, and a short piece of sterile rubber tubing, to which the needle is attached. Both salvarsan and neosalvarsan should be used only when fresh. They oxidize readily and so deteriorate rapidly and be- come poisonous. THE ADMINISTRATION OF MEDICINES 429 Before the injection, in either case, the stomach and bowels should be empty. Afterward the patient should rest quietly in the recumbent position for several hours. An injection of salvarsan may be followed by a severe reaction with headache, nausea, malaise, severe pain, and chills. The patient and the urine should be watched closely for several days following (especially in diseases of the kidneys) as the arsenic, which is very irritating, is eliminated by the kidneys and may cause suppression. Several days later a further reaction may occur with dizziness, deafness, stupor, and sometimes uncon- sciousness. These symptoms are thought to be due to irritation of the nervous system by the toxic products set free from the parasites killed by the injection of salvarsan. Symptoms of arsenic poisoning, diarrhea and skin eruptions, etc, may also develop. Neosalvarsan is said to be less toxic, but may be followed by a reaction with chill, fever, and impaired heart action. II. Through the Lungs by Inhalation.—Drugs may be given by inhalation for either a local or systemic effect. The systemic effect is produced immediately because of the large surface area of the lungs and rich supply of blood vessels. Medicated steam is given for a direct local effect. The method of administration is discussed in the chapter on Diseases of the Eye, Ear, Nose and Throat. Inhalations of fumes from burning calomel are sometimes given for a direct local effect in syphilitic conditions of the throat. Fumes from stramonium leaves may be inhaled for a direct local effect on the bronchial tubes in asthma. Am- monia gas from ammonia water or smelling salts, amyl nitrite and oxygen are all inhaled for a systemic effect. Ether, chloro- form and nitrous oxid gas are inhaled for a general anesthetic effect. The method of administering anesthetics may be learned from text books on surgery. Method of Administration.—Ammonia gas is inhaled as an emergency heart and respiratory stimulant in fainting or mild collapse. Extreme care should be taken to protect the eyes and to avoid too strong or prolonged administration as the gas is extremely irritating. Cold compresses may be used to protect the eyes. Amyl nitrite is given by inhalation to relax the coronary arteries and relieve an attack of angina pectoris or to relax the spasm of the muscles of the bronchial tubes in asthma. The drug comes in small glass capsules or "pearls," each containing mimims three to five, which should be broken in a handkerchief or gauze wipe and held to the nose of the patient for a few minutes only. The patient's face becomes flushed, the breathing more rapid, the pulse rapid and soft, showing that the blood vessels are relaxed. The patient complains of fullness and throbbing in the head. If too much is given he will suffer from severe headache due to excess blood in the head. Oxygen gas is given by inhalation, most commonly in condi- 430 THE PRINCIPLES AND PRACTICE OF NURSING tions such as pneumonia or edema of the lungs, accompanied by cyanosis, and in failure of the circulation. It is also used in bronchitis, anemia, phthisis and asphyxiation from coal-gas. The patient's critical condition indicates the extreme care with which the gas should be administered in order to get the best results. The oxygen is contained in an "oxygen tank" under compression. For administration the gas is passed through a bottle of water which is fastened to the tank. This bottle con- tains a rubber cork through which two glass tubes are inserted. One tube is long and extends well into the water. This tube is connected by rubber tubing to the outlet of the oxygen tank. The second glass tube is short, extending only to within an inch or two of the water. To this tube is attached a long piece of rubber tubing (long enough to reach to the patient) with a funnel attached. In this way the gas is made to pass through water before reaching the patient. The purpose is (1) to moisten the gas; (2) to indicate, by the bubbles formed, the rate and amount of gas passing through so that it may be regulated. The rate and amount should be sufficient to make small bubbles only. Otherwise the gas will be wasted. The nurse must see that the tubes are properly connected. Otherwise the cork will be blown out of the bottle, causing waste of oxygen and unnecessary delay in its administration. She must see that it is properly regulated and administered. The funnel should be held at the side of the patient's face a little above the nose, and tilted slightly forward so that a stream of oxygen will flow continuously over the face. If held directly in front of the face it should be at least two or three inches away. Otherwise the patient will be forced to inhale again the air exhaled from his own lungs. In directing the stream of oxygen, it must be remembered that this gas is heavier than air. If the funnel is held below the nose and directed downward the patient will receive none of the oxygen and the gas will be wasted. The inhalation is continued until the symptoms of cyanosis, etc., are relieved. Oxygen tends to dry mucous membranes. The patient's lips and mouth should be frequently moistened. Sometimes steam inhalations are given at the same time as the oxygen in order to prevent the drying and irritation of the mucous membrane of the respiratory tract. When oxygen inhalations are necessary a nurse should see that there will always be a sufficient supply on hand. A second tank should be in readiness for immediate use when required. Any delay would endanger the life of the patient. Calomel inhalations are sometimes given in syphilitic condi- tions of the throat. A canopy is arranged over the patient to prevent the escape of the calomel fumes. The powdered calomel is placed on a tin plate which is kept hot by means of an electric stove or alcohol lamp. The amount of calomel and the duration of the treatment should be ordered by the doctor. The patient should be closely watched during the procedure. The nurse must avoid inhaling the calomel fumes as, in a normal person THE ADMINISTRATION OF MEDICINES 431 this would cause mercurial poisoning, the early symptoms of which are a profuse flow of saliva with soreness and bleeding of the gums. Stramonium Inhalations.—Stramonium leaves may be made into cigarettes or burned in a receptacle which will not be broken by the heat. The fumes may be inhaled through a cone fitted over the receptacle. They relax the spasm of the involuntary muscles of the bronchial tubes in asthma. III. By Hypodermoclysis.—By this method large amounts of a normal saline or other isotonic solution may be injected into the loose subcutaneous tissue under the breasts or in the abdo- men, back or buttocks. The rate of absorption will depend upon the condition of the circulation and the tissue needs. The fluid should be rapidly absorbed, otherwise the mechanical pressure caused by its accumulation may cause death of tissue cells and gangrene. For the method of giving a hypodermoclysis see Chapter XXXII. IV. By Intramuscular Injection.—Irritating drugs such as mercury salicylate, ergotin, digitalis and sometimes camphor are injected deep into the muscles of the buttocks, back, chest and sometimes the limbs. When given in this way they are usually readily absorbed, depending upon the circulation. If given sub- cutaneously they are less readily absorbed so that they are very painful and are apt to produce sterile abscesses owing to their irritating effect on the tissues. The injection is made with a large, firm needle attached to a hypodermic syringe. The air is expelled from the syringe and the needle is inserted straight into the tissues. The part should be prepared as for a hypodermic injection and thoroughly massaged after the injection to hasten absorption. Intramuscular injections are usually given by a doctor. When a patient is receiving repeated injections of mercury salicylate he should be closely watched for early symptoms of poisoning. These are an increased flow of saliva and sore, tender or bleeding gums. The mouth should receive very careful attention. V. Subcutaneously (hypodermatically).—Certain drugs may be injected under the skin when (1) a rapid action is desired, and (2) when, for any reason, it is inadvisable or impossible to ad- minister the drug by mouth. Only such drugs which are readily dissolved and absorbed and which may be given in a concen- trated form or small bulk may be used. A large amount given in this way would cause pressure and injury to the tissues. All drugs used for hypodermic injection must be pure and sterile. They are put up in the form of tablets or in solution ready for use. Dangers to be Avoided in Giving a Hypodermic Injection.— 1. The formation of a sterile abscess from an irritating drug or an infective abscess from an unsterile syringe, needle, solution, or the unclean skin of the patient or hands of the nurse. To avoid an infective abscess, the nurse's hands should be 432 THE PRINCIPLES AND PRACTICE OF NURSING clean, the solution, syringe and needle must be sterile and the patient's skin where the injection is to be made should be cleansed and disinfected with alcohol. To avoid a sterile abscess and the resulting pain, when giving an irritating drug such as camphor, the needle is directed straight into the fleshy parts such as the buttocks and thighs. As in all hypodermic injections, the part should be rubbed briskly before the injection in order to bring the blood to the surface so as to hasten absorption and prevent irritation. All drugs must be thoroughly dissolved. After the injection gentle massage also hastens absorption. 2. Injury to a Superficial Vein or Nerve.—To avoid this the injection is given into the fleshy parts such as the front of the thighs, the outer surface of the arm or forearm, avoiding the course of the blood vessels or nerves. 3. Breaking the Needle in the Tissues.—A bent needle should never be used. The injection should never be made over a bone, not only so as to avoid the danger of breaking the needle but, also, of causing injury to the periosteum. To avoid the danger from a sudden, jerky movement, it is always wise to explain to the patient what you are going to do, assuring them that they will merely suffer the slight pain from the prick of the needle. A nurse should never attempt to give a hypodermic injection to a delirious patient without the assistance of another nurse. 4. Pain.—To avoid pain a sharp, clean needle only should be used. It should be inserted quickly as this causes less pain than when slowly inserted. The needle and the drug should be injected under and not into the skin so as to cause absorption and at the same time to avoid irritation of the superficial nerves in the skin. For local treatments when a local anesthesia is desired, cocain is injected into the skin under the epidermis (intracutaneously) to deaden these superficial nerves. When making a hypodermic injection, in order to avoid injecting the drug into the skin or superficial tissue, a cushion of flesh should be grasped between the left thumb and forefinger. The flesh should be firm and the skin tight and smooth. If the skin is wrinkled the injection cannot be properly made. The needle should be slanted at an angle of about 45 degrees and inserted its full length, then withdrawn slightly and the fluid injected slowly and gently. After a slight pause the needle is withdrawn gently. A sponge is held over the point of injection for a mo- ment and the part is then gently massaged to hasten absorption. Method of Preparing the Needle and Syringe.—The technique used should always be as simple as possible. In an emergency it will be necessary to give the medication without the loss of a single moment. At all times simplicity makes for efficiency and lessens the danger of infection. The method of preparing the syringe will depend upon the kind used. When the syringe is made of glass both needle and syringe may be sterilized by boil- ing for one minute. For emergency use a sterile syringe and THE ADMINISTRATION OF MEDICINES 433 needle may be kept in a package wrapped in a sterile gauze wipe. When a metal syringe or a glass syringe with a rubber washer is used, it must be sterilized by alternately drawing up and expelling alcohol 70 per cent. The needle may be attached to the syringe and sterilized in the same way or it may be placed in a spoon, covered with water and boiled over an alcohol lamp. For emergency use or when used for a patient at frequent inter- vals, the syringe and needle may be kept sterile by immersion in a solution of alcohol 70 per cent. Method of Preparing the Drug.—When sterile tablets are used they must be dissolved in distilled water. Ordinary tap water may contain salts which alter the nature of the drug. The water should be boiled in a spoon. The tablet should be dropped from the bottle directly into the water so as not to contaminate it. When the drug is thoroughly dissolved it may be drawn up into the syringe. When the piston can be removed from the syringe the tablet may be placed directly in it and sufficient sterile water drawn up to thoroughly dissolve it. Solutions for hypodermic injections are put up in sterile bottles with a rubber stopper. Before withdrawing the solution the rubber stopper is disinfected by immersing it in alcohol 70 per cent. The sterile needle, attached to the sterile syringe, is plunged through the rubber and the required amount is with- drawn. The needle is then covered with a sterile sponge satu- rated with alcohol and the medication is carried to the bedside. The air is expelled from the needle and syringe and the injection is given with the above-mentioned precautions. After use the needle and syringe should be sterilized as before. The needle should be thoroughly dried, to prevent rusting, by repeatedly inserting and drying the wire which accompanies the needle. When dry the needle is put away with the wire inserted. The articles necessary for a hypodermic injection are usually kept on a tray. Before putting the tray away a nurse should see that it is fully equipped, ready for instant use. VI. By Mouth.—Medications are given by mouth in solution or in the form of pills, tablets or capsules, etc. In giving reme- dies a nurse should consider the following important factors: 1. The effect desired and how to obtain the best results. 2. The nature of the drug and its possible injurious effects. 3. How to make the dose as palatable as possible. Effect Desired.—It is important to know why a medication is being given in order to know whether it should be well diluted or given in a more concentrated form. All drugs given for a systemic or a remote local effect, and, therefore, to be absorbed, should be well diluted in order to aid absorption. Water is the best solvent. Unless otherwise ordered all drugs (except oily preparations) are given with water. The effect desired also gov- erns the time of administration prescribed by the doctor. Drugs intended to be absorbed are usually given after or, if altered by the gastric juice, between meals because there is more blood in 434 THE PRINCIPLES AND PRACTICE OF NURSING the stomach and intestines and absorption is taking place. For instance, sodium bicarbonate, when given for acidosis, is usually given between meals. If given after meals it is broken up by the gastric juice, combined with hydrochloric acid, and absorbed as sodium chlorid. It should never be given in a capsule but should be dissolved in a glass of water or in a medicine glass of water and followed by more water. Water should be given freely with all drugs given for a dia- phoretic, diuretic or narcotic effect, etc. A hot drink following the administration not only aids absorption but also aids the action of the drug. After giving such drugs as the salicylates, Dover's powder and other opium preparations which cause in- creased perspiration care should be taken to prevent the patient from becoming chilled. To give narcotics intelligently a nurse should know the time taken by the various drugs to act. She should see that the patient's surroundings and his mental and physical condition are all inducive to sleep and that nothing occurs to disturb his sleep. The depressing effect of all narcotics should be remembered. The patient should be closely watched and the character of the sleep noted. Some drugs, such as aromatic spirits of ammonia, although given for a systemic effect, do not owe their stimulating action to absorption but to a reflex action following the irritation of nerve endings in the mucous lining of the mouth, etc. Such drugs must be diluted sufficiently to prevent irritation to the tissues, but not to the extent of preventing the irritation of the nerve endings. One-half to one dram of aromatic spirits of ammonia in one-half a medicine glass of water gives about the proper proportion. Syrup cough mixtures given for a soothing or sedative effect on the mucous lining of the respiratory tract are usually given undiluted. Drugs given for a local effect on the stomach are only slightly diluted. They may be given before meals when the stomach is empty and at rest to soften mucus, etc., or to stimulate the flow of gastric juice. They may be given during or after meals to supply a deficiency of hydrochloric acid or enzymes or to coun- teract abnormal conditions present. For instance, bicarbonate of soda given before meals will soften mucus and stimulate the flow of gastric juice. During and after meals it will neutralize hyperacidity. Drugs are usually diluted with cold water, but when a drug, such as peppermint, is given for a carminative effect hot water should be used. The heat greatly aids in the expulsion of gas from the stomach or intestines. Many other examples might be given to show that the effect of any medication depends not only upon the nature and action of the drug but also upon the method of preparing and giving it to the patient. For this the nurse is entirely responsible. She should not give a medication without finding out why it is being given and the effect desired. THE ADMINISTRATION OF MEDICINES 435 Nature of the Drug and its Possible Injurious Effects.—Many drugs, such as dilute acids, iron, arsenic, salicylates, iodids, bro- mids, digitalis and mercury are irritating to the mucous lining of the stomach and may cause pain, nausea and vomiting. All such drugs should be well diluted or the patient should be given a glass of water following. They are given after meals usually so that they may be diluted with the stomach contents and not come in contact with its walls. Dilute acids such as hydro- chloric acid and liquid preparations of iron are also destructive to the teeth. They should be given through a glass tube, or a straw which may be thrown away after use—one long straw may be cut into two or three pieces and in this way serve several patients. Dilute hydrochloric acid is frequently added to a drinking glass of water and the patient is instructed to sip this during the meal, in this way approximating the normal secretion in the stomach. The mouth should receive careful attention when such drugs are given. Some doctors give bicarbonate of soda with aspirin and other preparations of the salicylates to lessen the irritation in the stomach and to prevent acidosis. To prevent the irritation due to calomel it is usually given in very small doses. For instance, one-fourth of a grain may be ordered to be given every fifteen minutes or every half-hour for six doses or until the total amount desired has been given. Sometimes patients find calomel gives less discomfort and nausea if given with bicarbonate of soda. This alkali was at one time given to prevent the formation of bichlorid of mercury by the union of calomel with hydrochloric acid. It is now known that bichlorid of mercury is not formed in the stomach in this way. How to Make the Medication Acceptable to a Patient.—There are a few drugs such as the bitter stomachics, quinin, gentian and nux vomica, etc., which owe their stimulating effect on the •appetite entirely to their bitter taste. These drugs are, there- fore, given undiluted with no attempt to disguise the taste. In all other cases the taste should be made as unobjectionable as possible. The drug should be diluted sufficiently to make it palatable and water should be given immediately afterward from a clean glass. The water should be cold. Ice may be held in the mouth before and after the medication in order to numb the taste buds. It is unwise to try to disguise the taste with milk or other food. This is likely to cause a distaste for food which is always to be avoided, especially with the very sick. While a nurse's manner should not be hurried when giving a dose of medicine to a patient, there should be no unnecessary delay. Hesitation on the part of the patient makes the medicine harder to take and more distasteful. Patients receiving iodids are apt to have a constant dis- agreeable taste in the mouth because iodin is eliminated in the saliva. A mouth-wash with an agreeable flavor should be used frequently. Castor oil, to most people, has a very disagreeable taste. There 436 THE PRINCIPLES AND PRACTICE OF NURSING are various* ways in which the taste may be disguised. It may be taken with whisky, brandy or peppermint or it may be emul- sified by adding lemon juice and bicarbonate of soda and taken while effervescing. These are all drugs, however, which can only be used with a doctor's order. The following method is simple, satisfactory and always permissible. The medicine glass is first rinsed with lemon juice. About a teaspoonful of lemon juice is poured in the glass, then the oil and on top of that more lemon juice. To this one or two small pieces of ice are added. The glass is then placed in a small saucer and surrounded with small pieces of chipped ice. The taste of the oil is much less disagreeable when cold. The patient is allowed to hold the ice in his mouth before and after taking the oil. The cold numbs the nerve endings in the mouth so that the sense of taste is lost. Orange juice, vichy, seltzer or an olive will often prevent the feeling of nausea which sometimes follows the taking of a dose of castor oil. When it is difficult for patients to swallow pills or tablets, etc., they should be broken up, powdered and dissolved. Powders which will not dissolve readily or which have a disagreeable taste may often be given in capsules. Compound licorice powder will not dissolve readily in water. It should be mixed into a paste with a small amount of water. Sufficient water should be added to enable the patient to swallow it. Adding too much water is apt to cause nausea. It should be followed by a drink of water. VII. By Rectum.—Drugs are most frequently introduced into the rectum for a direct local effect. The purpose may be to relieve distention, diarrhea, constipation or pain and to apply a remedial application to a diseased mucous lining. Drugs are also given by rectum in the form of a nutritive, stimulating or sedative enema, to produce a systemic effect. Paraldehyde is frequently given by rectum, as a general sedative, because of its disagreeable taste and odor. Drugs may also be given by rectum to produce a remote local effect, as for instance, when potassium acetate is given in an enteroclysis or proctoclysis to stimulate the kidneys and increase the flow of urine. Drugs are introduced into the rectum in the form of sup- positories, enemata, enteroclyses or proctoclyses. The enema, enteroclysis and'protoclysis are discussed in Chapters XI and XXXI. Rectal suppositories may consist of concentrated food, soap, glycerin or plain or medicated cocoa-butter. They are pre- pared in the shape of a cone. They retain this shape at a normal or room temperature but when introduced into the rectum are dissolved by the heat of the body. Drugs contained in them are then set free. Varieties of Suppositories Used.—1. Evacuant.—Soap and glycerin suppositories are used to cause the expulsion of feces. They are particularly valuable when the feces are in the lower THE ADMINISTRATION OF MEDICINES 437 bowel or rectum, but cannot be expelled because the tight or sen- sitive anal sphincter will not relax. The irritation caused by the presence of the suppository stimulates the rectum to expel it. Glycerin suppositories for adult use are larger than those used for infants and young children. Long, thin suppositories are used for infants. Soap suppositories may be purchased ready for use, but may easily be made by taking a splinter of white soap and holding it in hot water until smooth and rounded to the required length and shape. It should be cone-shaped and may be from one to three inches long. 2. Astringent suppositories consisting of tannic acid, bella- donna, and glycerin are used in dysentery and diarrhea to con- tract the tissues, check bleeding, relieve pain and dry up the secretions. Bismuth suppositories are used in the same condi- tions. The bismuth forms a coating on the mucous lining and prevents irritation. In this way it checks diarrhea caused by the irritating contents in the intestines. 3. Ice suppositories are sometimes used to check local bleed- ing or to relieve local inflammation. An ice suppository may be made in the same way as the soap suppository. It must be of a suitable shape and size, round and smooth and free from all sharp edges. 4. Anodyne or local sedative suppositories are used for hemorrhoids, dysentery, diarrhea, rectal abscesses or in post- operative conditions in which it is necessary to limit peristalsis and keep the rectum at rest. The drugs commonly used are cocain, opium and belladonna added to cocoa-butter. Cocain relieves pain and by contracting the blood vessels relieves bleed- ing if present. Opium and belladonna relieve pain, check peri- stalsis and dry up secretions. 5. Suppositories containing opium or veronal acetate are given for a general sedative effect when for any reason it is inad- visable to give the medication by mouth. 6. Specific Suppositories.—In malaria large doses of quinin given as a specific frequently cause severe gastric disturbances on account of the irritating effect of the quinin on the lining of the stomach. To prevent this quinin may be given in the form of a suppository. Method of Procedure.—A suppository should be well lubri- cated with a small amount of petrolatum or other lubricant before insertion. It should be carried to the bedside in a gauze wipe or a small piece of gauze. When inserting the suppository a nurse wears a glove and inserts the suppository as far as the finger will reach. Pressure is then applied over the rectum for a short time until all desire to expel the suppository has passed A patient should never be permitted to insert a suppository. Suppositories should always be kept in a cool place to keep them from melting. It is necessary to keep glycerin suppos- itories on ice. Vaginal and Urethral suppositories are also used. 438 THE PRINCIPLES AND PRACTICE OF NURSING Vaginal suppositories are used as a means of applying local remedies to the cervix or walls of the vagina. A vaginal sup- pository is inserted in the same manner as a rectal suppository. The patient should lie flat on her back with her knees flexed. Vaginal suppositories are larger than rectal suppositories. Urethral suppositories are much smaller and are shaped like a fine pencil. They are well lubricated and gently inserted and pushed forward until the entire length has been introduced. VIII. By Inunction.— Oily or fatty preparations are rubbed into the skin either for a local or systemic effect. The remedies most commonly applied in .this way for a systemic effect are cod-liver oil, olive oil or cocoa-butter for malnutrition or deli- cate infants, and mercurial ointment in syphilitic conditions. Method of Application.—The amount of absorption and the beneficial effects derived from the inunction will depend upon the condition of the skin and circulation, the extent of surface to which the application is made and the thoroughness with which the ointment is rubbed in. Method of Applying Cod-Liver Oil, Olive Oil or Cocoa-butter. —The application may be made to the chest, abdomen, back, limbs or to the whole body. The skin should be washed with hot water and soap to remove all fatty substances as these prevent absorption. It should then be dried. The oil should be warmed and rubbed in with the palm of the hand until absorbed. A circular movement is used in rubbing. Method of Applying Mercurial Ointment.—As mercurial oint- ment is irritating and poisonous a limited amount is used and it is applied to a small surface only. The doctor orders the amount of ointment to be applied. To aid absorption the ointment is rubbed into regions where the skin is thin. These regions are the axilla, front of the elbow, inner surface of the thigh, and the groin. To prevent irritation the ointment is never applied to the same area on successive days. The above areas may be used in rotation on successive days. This is called a "course" of applications. The treatment is then emitted for a day and the parts are washed to remove, any of the ointment which may remain in the pores of the skin. The "course" is then begun again in the same order. The area to which the application has been made should be indicated on the chart each day. The preparation of the skin is the same as in applying cod- liver oil. A nurse should always wear a glove in applying mercurial ointment. The bare hand should never be used on account of the danger of absorbing the poisonous drug. The amount of ointment usually prescribed is from one-half to one dram. A little at a time should be applied and thoroughly rubbed in until absorbed. CHAPTER XXVIII THE NURSING CARE IN MEDICAL DISEASES The importance of expert nursing care in all medical diseases has already been noted. There are certain classes of disease where the patient's life often depends more upon the nursing care than upon any other factor. In the limited scope of this book only a few diseases in which the nursing care is one of the greatest, if not the most important factor in the patient's recov- ery, can be discussed. General Principles to be Considered.—Before discussing the specific treatment of any disease, it will be well to remind our- selves of the four important factors, in the treatment of every disease, upon which recovery mainly depends. These principles were laid down in the first chapter of this text on nursing, for they form the basis and keynote and are the very substance and essence of all good nursing. They are particularly important when a disease is apt to be prolonged. 1. Sufficient physical and mental rest and sleep must be obtained if possible. , 2. Annoying symptoms and discomforts which sap the pa- tient's vitality and often obscure the true state of the system must be relieved. 3. Vital resistance by proper feeding must be maintained. 4. Elimination of effete materials by the kidneys, bowels, and skin must be maintained. These principles are particularly applicable to the care of medical diseases and are to be applied in the treatment of the body as a whole, and also in the treatment of disease of any organ. The symptoms of any disease are merely the manifesta- tions of Nature's forces at work in the application of these prin- ciples. For instance, pain is Nature's insistent demand (one which we are forced to heed) for absolute rest of a diseased part so that the cells may devote their entire attention to repair; difficult breathing in heart disease forces one to rest; vomiting, diarrhea and coughing are means of eliminating substances which not only irritate but interfere with function; an elevated temperature increases the vital resistance and aids the body to combat bacteria; when a part is diseased, vital resistance by proper feeding is maintained by sending an increased and free supply of blood to it. This effort to meet the normal demands of the body means a tremendous loss of vital energy, and if continued will wear the 439 440 THE PRINCIPLES AND PRACTICE OF NURSING patient out. The treatment of disease must therefore be to remove the cause of the trouble and relieve the symptoms when they are so intense or so prolonged as to tax the patient's strength. Only those diseases most commonly met with and which re- quire special nursing care will be discussed here, but the general principles laid down may be applied to similar conditions having features in common. NURSING CARE IN DISEASES OF THE CIRCULATORY SYSTEM The nursing care is the most important factor in the treatment of diseases of the heart and blood vessels. The doctor carefully examines the heart with his stethoscope, etc., determines the lesions present, makes a very careful diagnosis, and then, as it were, forgets it. That is, in the treatment he is guided not by the lesion found, but by the degree to which the normal reserve force of the heart has been exhausted. This is indicated by symptoms of distress, indicating impaired function in various organs due to deficient circulation. The. proper functioning of every organ in the body, including that of the heart itself, de- pends upon the ability of the heart and blood vessels to main- tain an efficient circulation. The heart, like other organs in the body, possesses a remarkable degree of reserve force which it may call upon. As long as the demands of the body are within the limits of this reserve force, even though there be serious lesions in the heart or blood vessels, no symptoms of distress will appear. When the demands are too great and the heart fails to supply an efficient circulation, the various organs are unable to function properly and symptoms of distress occur. The chief duties of the nurse are to so regulate these demands that the heart's reserve force will never be exhausted but will be conserved in every way possible until fully restored. In this way the patient may be restored to a normal, useful, happy life. To understand how to perform these duties properly we must remember the factors which control the work of the heart. These are the cardiac muscle, the accelerator nerve, the inhibitory or vagus nerve and the resistance offered by the peripheral blood vessels. Whatever increases the demands on the heart muscle tends to exhaust the reserve force; whatever stimulates the accelerator nerve makes the heart beat faster and robs the nor- mal resting period and exhausts the heart muscle; whatever stimulates the inhibitory nerve in a rapid, irritable or failing heart slows the rate and lengthens its resting period; whatever abnormally contracts the blood vessels or raises the blood-pres- sure increases the demands on the heart and exhausts its reserve force. If we understand the diseases of the heart, as explained in the lectures on medical diseases, if we have examined diseased THE NURSING CARE IN MEDICAL DISEASES 441 hearts and have a picture in our minds of the conditions under which the heart may be struggling we will be more impressed with the need for saving the heart in every way possible. For instance, if we realize that in pericarditis every beat of the heart causes severe pain and that every extra demand upon the heart and every unnecessary beat not only mean increased pain but an aggravation and spreading of the inflammation, we will try to lessen the number of beats and rest the heart. If in peri- carditis fluid collects in the pericardial sac, the pain may be relieved but the distress and danger and the need for careful nursing will be still greater because the pressure on the heart interferes with its action even more than the pain. The heart may fail altogether to beat against the increasing pressure. Again, in myocarditis, if we remember that the work of the heart depends upon the myocardium and that one of the results of inflammation is always partial or complete loss of function we will realize that just as few demands as possible should be made upon the heart. The same is true in endocarditis, or in either stenosis or regurgitation at any of the heart valves. The heart will dilate, its muscle will increase in thickness and strength to its utmost capacity in order to overcome the difficulty and meet the demands of the body. This is the heart's reserve force. When pushed beyond this limit, its strength is overdrawn and the heart fails. The early symptoms which indicate a failing heart and which demand treatment are breathlessness, increased pulse rate, dis- tress, discomfort or pain about the region of the heart caused by some effort normally performed with comfort. Later symp- toms are dyspnea, orthopnea, cyanosis, cardiac cough, cardiac asthma or fluid in the pleural sac due to deficient circulation in the lungs; scanty urine with albumin and casts due to poor cir- culation in the kidneys, jaundice and ascites due to congestion in the liver; edema of the extremities and a rapid or irregular pulse. The Nursing Care.—In most diseases of the heart we must re- member that we are dealing with an infection, or the result of an infection in a vital organ which cannot be treated by surgical measures nor greatly relieved by local applications or drugs. The treatment must consist chiefly in building up the patient's resistance to the infection by improving his general health. Rest is the first essential. The degree of rest necessary varies with the stage of the infectious process and the amount of reserve force (indicated by the symptoms) which the patient's heart possesses. As long as fever, which is due to the infection, is present rest in bed is necessary. When the limit of the heart's reserve has been reached and even slight exertion causes dyspnea, then absolute rest of mind and body is essential until the reserve is restored. This means freedom from all physical, mental or nervous causes of strain or whatever throws additional work upon the heart. The patient must remain in bed. 442 THE PRINCIPLES AND PRACTICE OF NURSING His position should be recumbent, if possible, to lessen the work of the heart but if breathing is difficult then use that posi- tion which affords the greatest comfort with the least strain. The mattress should give firm support. When propped up the support must be firm, the head supported, the arms supported, not resting on chest or abdomen. He must not be allowed to slip down in bed. The pillows must not be allowed to push his shoulders forward making his back rounded and his chest hollow. His chest should be thrown forward and not allowed to cave in, for the lungs must have free room for expansion. A Gatch bed is most desirable for such patients. Nothing should be allowed to interfere with breathing, such as the head unsupported and falling forward on the chest, or the weight of an ice-bag, poultices or bedclothes. When the patient leans forward there should be a proper rest to lean upon. Sometimes the patient is more com- fortable sitting up in a chair and leaning forward. This pro- vides better circulation in the lungs and brain, although the extremities may suffer. For dropsy the patient must be in bed with the extremities elevated; massage and a firm bandage may improve the circulation. In giving treatments, in the use of the bedpan, and in feeding the patient all exertion and strain should be avoided. When an ice-bag is applied to relieve pain or stimulate the heart muscle, its weight should always be supported. (See Chapter XVI.) All causes of mental or nervous strain should be avoided. The patient should be free from worry, excitement, irritation or anger. He must be saved even from thinking for himself, as far as pos- sible, for it often exhausts a sick person more to have to think and decide for himself than to act for himself. Sleep is essential, for the heart cannot regain strength with- out sleep. No treatment will benefit if the patient is worried or troubled by unpleasant dreams or disturbed sleep. Sedatives are frequently necessary. Comfort is essential and every known art should be used to insure it. In severe cases visitors should be excluded. The breathless patient should not be forced to talk or even to listen to conversation. The Room.—The surroundings and the whole atmosphere created by the place, the doctors and nurses greatly influence the patient's health. In an illness apt to be prolonged, the men- tal attitude has a marked effect on the progress. The room should be bright, cheerful and quiet, the surroundings congenial, free from disorder or confusion. Fresh air is essential as the patient should get all the oxygen possible with the least amount of effort. The proper temperature and humidity will lessen the difficulty in breathing and add greatly to the patient's comfort. When the temperature and humidity of the air are increased the discomfort of the patient and difficulty in breathing are most distressing. The care of the skin is very important, as the impaired circula- THE NURSING CARE IN MEDICAL DISEASES 443 tion and nutrition with a prolonged illness make bedsores a real danger. Chafing and irritation are to be particularly avoided with edema. Daily cleansing baths and frequent massage are given to refresh the patient, stimulate the circulation, and keep the skin in good condition. The diet has a very marked bearing on the patient's comfort and recovery. The circulation is impaired in the digestive tract so that the appetite and digestion may be poor. Fermentation and putrefaction with dilatation of the stomach and distention may follow, and this greatly interferes with the breathing and also with the action of the heart. To prevent this the mouth should be kept clean and the food carefully regulated. It should be tempting, given in small amounts at fairly frequent intervals. Overeating or drinking should be avoided. The patient should be instructed to chew the food thoroughly and to take small mouthfuls, especially when troubled with difficult breathing. Do not force food which causes distaste or discomfort. Food should never be forced because, if the patient cannot be tempted, the digestion is at fault and we must guard against indigestion. Chewing food is also sometimes too great an effort for the patient. Give food which the patient likes if it does not disagree. Avoid articles which cause distention such as beans or cabbage, etc With a failing heart the diet should be light and dry. Fluids are restricted because they increase the edema and add to the burden of the heart. The amount given should be meas- ured and charted. Food should be given frequently enough to avoid faintness. To avoid faintness or sleeplessness during the night, due to hunger, a dry biscuit and a small glass of milk may be given before bedtime and again early in the morning. Regulation of the bowels is also important in order to avoid distention and auto-intoxication which is a predisposing factor in arteriosclerosis and hypertension. The stools should be ex- amined for evidence of fermentation or putrefaction. Free purg- ing is frequently ordered to relieve edema; the patient should be watched closely as this may be exhausting. The urine may be scanty on account of the impaired kidneys. It should be carefully measured and examined. The amount should be compared with the intake of fluids to determine the ability of the kidneys to eliminate water. Therapeutic Baths.—Baths much above or below the body temperature should never be given without a doctor's order. They have a marked effect on the peripheral circulation and therefore upon the heart. Warm baths act as a sedative and sometimes give relief. The Nauheim baths or sea bathing are sometimes ordered to tone up the whole system. Exercise.—When the reserve force is restored, the patient is gradually allowed more exercise. A certain amount of exercise is good for the heart, in order to train and strengthen the muscle, providing one keeps within the limits. The doctor prescribes the amount of exercise and the nurse watches the effect on the 444 THE PRINCIPLES AND PRACTICE OF NURSING patient. If no symptoms of distress appear the exercise is bene- ficial. Graduated exercises are usually prescribed while in the hospital. Exercise which gives pleasure without discomfort is best as the mental side is important. When fit, exercise in the open air is best. It is important to remember that exer- cise enjoyed with comfort one day may be quite impossible another day or under different conditions. The weather, climate and the patient's condition all have an important bear- ing. For instance, exercise possible when the atmosphere is high and dry may be quite disastrous when the atmosphere is low and humid. Again exercise possible at one time may be quite dangerous where the heart is embarrassed by worry, want of sleep or by gastric disturbances, etc. The patient is instructed regarding those conditions which embarrass the heart and is encouraged to feel that the lesion in his heart need not prevent him from living a useful, happy life providing he lives within the limit of his reserve strength. He needs no one to tell him when this is the case, as his own sensations are the best guide. Drugs.—Digitalis is commonly used in failure of the heart when the persistent, rapid beat threatens to exhaust the heart. Digitalis slows the heart beat, rests the heart, and strengthens the muscle. It also acts as a diuretic so gives relief in dropsy. When digitalis is given watch for a slow pulse, nausea or diarrhea as these symptoms indicate poisoning. Nitrites (amyl nitrite or nitroglycerin) are sometimes given when contracted blood vessels and a high blood-pressure increase the resistance and strain on the heart. They dilate the blood vessels and lower the pressure. When amyl nitrite is given watch the patient for a flushed face, throbbing in the head fol- lowed by faintness and giddiness; these indicate that the drug should be stopped. Bromids, veronal and when necessary chloral or opium may be prescribed for sleeplessness, anxiety or worry, etc Treatments.—Aspiration of serous cavities—the abdominal, the pleural or pericardial—may be necessary for the relief of dropsy. Dry cupping may be ordered for the relief of pulmonary congestion, and venesection for the relief of venous congestion with cyanosis. NURSING CARE IN DISEASES OF THE ARTERIES Arteriosclerosis may be (1) either the effect or the cause of high blood-pressure; (2) the effect of poisons in the blood, as in syphilis, typhoid, Bright's disease, diabetes, gout, or constipa- tion, etc., or (3) the effect of senile decay—the blood-pressure is normally increased with old age. Strain, mental, physical or nervous, increases the tendency to arterioslcerosis or "hardening of the arteries." In this disease the lumen of the arteries be- comes occluded, many capillaries may disappear altogether, and THE NURSING CARE IN MEDICAL DISEASES 445 the heart becomes enlarged with degeneration of its "muscular tissue. The result is diminished blood supply and therefore, impaired function in the various organs affected. If the coro- nary arteries are affected, every effort of the poorly nourished heart muscle may be accompanied with distress, pain and breath- lessness. Angina pectoris may result. If the renal arteries are affected, degeneration with Bright's disease follows; if the arteries of the brain, degeneration, softening and possible rup- ture and hemorrhage from the weakened blood vessels resulting in apoplexy—this is the great danger in arteriosclerosis. The results of arteriosclerosis in the old are very familiar. This condition accounts for the ease with which they become either physically or mentally fatigued; the pains and cramps in the muscles of the legs with exercise or lying in bed; cold or numb- ness or pain in the extremities; sensitiveness to cold, loss of appetite and impaired digestion; the thin "tissue paper" skin and the small amount of oozing which occurs when their tissues are cut. Diminished blood supply in the brain results in loss of memory, fatigue on attempting to concentrate, irritability, uncertain temper and delusions. Inability of the circulation to adjust itself quickly causes giddiness on standing up quickly or with sudden exertion. Old people are apt to doze frequently when sitting up on a chair, due to lack of blood in the brain, but may sleep poorly when lying down. The Nursing Care and Treatment aim to avoid, as far as possible, conditions which aggravate the disease and cause con- traction of the arteries or increased blood-pressure. All excesses in exercise, food, drink, and habits should be avoided. The functions of the skin, the kidneys and bowels should be care- fully regulated by warm baths, drinking water freely, and the avoidance of constipation. Exposure to cold contracts the blood vessels and should be avoided by regulation of the clothing, by warmth to the extremities, and hot drinks to relax the blood vessels. Old people in particular stand exposure to cold badly— cold air, baths, or being deprived of their customary clothing and surroundings. When not allowed to wear flannel underwear in bed they should have extra blankets or a hot-water bag and fre- quent massage to the limbs to restore the circulation and prevent cold and cramps, etc. When the arteries of the brain are affected, the danger of apoplexy must always be remembered. All causes of worry, excitement, anger or irritation must be avoided, as they greatly increase the supply of blood and the blood-pressure in the brain, shown by the flushed face and prominent blood vessels. Slight, petty causes of irritation particularly upset the patient. The same is true in angina pectoris. Particular care should be taken to observe moderation in food, drink and exercise and to avoid constipation or foods which cause distention. Sudden death frequently occurs from "acute indigestion" combined with some unusual exertion and strain on the heart. Nitroglycerin or amyl nitrite is usually ordered to dilate the blood vessels, and 446 THE PRINCIPLES AND PRACTICE OF NURSING bromids or morphin to relieve the pain and to quiet and relieve the patient from the fear of impending death. Aneurysm is due to a diseased condition of the arteries caus- ing them to bulge where the wall is thin and is accompanied by symptoms of pressure on neighboring structures—the lungs, bronchus, trachea, esophagus (with difficulty in swallowing), veins, ribs, sternum or spine, etc. Pressure, constant pulsation, and corrosion of bone cause very severe, persistent boring pain. The danger in aneurysm is sudden death from rupture of the diseased artery. The Nursing Care is to avoid all conditions which will tend to raise the blood-pressure or increase the force of the heart- beat. THE NURSING CARE IN ANEMIA Anemia means the loss or destruction of red blood cells, of hemoglobin (the oxygen carriers), or of both. Every cell in the body suffers and smothers for the want of oxygen, so neces- sary for all the processes of metabolism. The result is muscular weakness, breathlessness and impaired function of every tissue and organ in the body. In pernicious anemia the marked cell destruction is shown in the greatly reduced red cell count and hemoglobin, the presence in the blood of abnormal red blood cells; the peculiar lemon color of the skin, fever, and increased urobilin and iron in the stools and urine. The patient becomes very weak and suffers from dyspnea, faintness, dizziness, pal- pitation and dyspepsia. The effect on the digestive system is seen in the lessened hydro- chloric acid in the stomach, loss of appetite, vomiting, diarrhea or constipation, abdominal pains, discomfort and distention. The patient suffers periodically from soreness or rawness, sometimes with ulcers, of the tongue and mouth which may extend to the throat. This causes pain in chewing and eating, especially hot, acid, or spiced food. The effect on the nervous system may be degeneration of the brain, cord and nerves with defects in sight or hearing, and par- tial loss of sensation, with numbness and tingling in the hands and feet. The Nursing Care consists in providing absolute rest and freedom from all conditions, mental or physical, which increase the strain on the heart and other organs. Fresh air, sunlight, quiet but cheerful surroundings, freedom from care or worry, and plenty of sleep are essential. Every atom of strength should be conserved. Anemic patients feel the cold and should be pro- tected not only for comfort, but to save energy otherwise used in keeping warm. Proper bathing, the care of the mouth, the regulation of the bowels and of the diet are extremely import- ant. Every effort should be made to improve the appetite and to build up the strength by a nutritious diet. It should be THE NURSING CARE IN MEDICAL DISEASES 447 plain, easily assimilated and contain foods rich in iron, such as eggs, spinach, fish and meats, etc. Extreme care should be taken during the periodic attacks of soreness and rawness of the mouth and impaired digestion; good digestion alternates with periods of bad. The drugs used in anemia are iron and arsenic. Iron is used to aid the formation of hemoglobin. When iron is given watch for an upset stomach and constipation. Arsenic is given to stimulate the bone marrow in the formation of red blood cells. When arsenic is given note if the eyes become puffy or if the patient complains of stomach trouble or a cold in the head. These symptoms indicate poisoning. Transfusions may be given to increase the volume of the blood, the number of red cells and hemoglobin, to increase the patient's resistance, and to stimulate the bone marrow. These treatments do not cure the disease but may prolong life for a number of years. (See "transfusion," Chapter XXXII.) NURSING CARE IN DISEASES OF THE KIDNEYS ACUTE NEPHRITIS, CHRONIC NEPHRITIS, UREMIA The Nursing Care and Treatment consist in removing the cause, if known, avoiding conditions which predispose to or aggravate the disease, finding the amount of work the diseased kidneys are capable of performing, regulating the diet, the habits and general hygienic care of the patient so as to rest and restore the kidneys, and treating the symptoms as they arise. The nursing care is the most important factor. This includes the care of the skin, strict attention to the diet, accuracy and care in the collection of urine specimens, intelligence in giving the treatments ordered, and care in avoiding anything which would increase the work of the kidneys. Nephritis means inflammation of the kidney. Complete rest is the first essential in the treatment of inflammation. This can only be provided by lessening the work of the diseased organ. The work can only be lessened by regulation of the diet, by lessening the wastes from tissue metabolism, by preventing in- fections, avoiding the use of irritating drugs, and by stimulating elimination through the skin and intestines. The Work of the Kidneys.—All the food which enters the body—protein, carbohydrates, fats, water and mineral salts— is finally burned and the ashes which remain must be eliminated from the body. The work of the kidneys is to eliminate prac- tically all the ashes resulting from the metabolism of protein, most of the salts, about four-fifths of the water, and a small amount of carbon dioxid. In addition, it must eliminate drugs taken into the body, germs which enter and multiply, and other poisonous products of disease from other parts of the body. The lungs, intestines, liver and skin also eliminate water, carbon 448 THE PRINCIPLES AND PRACTICE OF NURSING dioxid, and small amounts of salt. In diseases of the kidneys, Nature saves the diseased organ by increasing the elimination of wastes through these pathways. The Work Performed by a Diseased Kidney.—A diseased kidney cannot perform its work properly. Sometimes it cannot eliminate the ashes of protein—urea, uric acid, creatinin, hip- puric acid, ammonia, etc; sometimes it cannot eliminate salts, and sometimes it cannot even eliminate water. When the kid- neys fail, even though the lungs, intestines and skin do their best to eliminate these products, waste will accumulate in the body with more or less disastrous results. The degree to which this occurs may be ascertained by a study of the symptoms, by the use of test diets, and by examinations of the urine and blood. Symptoms to be Observed.—The products of protein metab- olism from which urea, etc, are made are extremely poisonous and if not eliminated may give rise to symptoms of suppression and uremia, the symptoms of which are drowsiness, headache, disturbance of vision, nausea, vomiting or diarrhea. Convul- sions, coma, and death may follow. In nursing, it is extremely important to watch for, and report the first symptoms. If salts are not eliminated, water will also be retained in order to dilute them and prevent irritation of the tissues; the result is edema. Salts are very irritating to the inflamed kidney, particularly sodium chlorid. If water is not eliminated the result is edema and anuria. Edema is usually seen first in the loose tissue of the eyelids and beneath the eyes. A high blood-pressure, arterio- sclerosis and a hypertrophied heart are almost always present, particularly in chronic nephritis. Symptoms of these diseases will then occur. (See diseases of the circulatory system.) Examination of the Urine.—Twenty-four-hour specimens are always collected and sent for examination. Extreme care should be taken in the collection of these specimens as the examination of the urine is the chief means of finding out how much work the kidneys are capable of doing and of determining to what extent the patient must be restricted in diet and normal habits of life. A nurse should also take an intelligent interest in the reports made, so that she will understand the diet and treatments ordered by the doctor and know how best to care for her patient. The specimens will be sent to the laboratory to be examined for the specific gravity and the presence of the abnormal con- stituents, albumin, epithelial cells, leucocytes and red blood cells, casts (hyaline, granular, epithelial, or waxy casts), blood and pus. The presence of casts indicates alteration, degeneration or destruction of the kidneys due to circulatory disturbance, toxic or inflammatory processes. Their presence in the order men- tioned indicates the severity of the disease.' The Esbach test is frequently used. It is a quantitative test used to indicate the total amount of albumin excreted in twenty- four hours. In acute nephritis there may be partial or complete suppres- THE NURSING CARE* IN MEDICAL DISEASES 449 sion. The urine will be highly colored, cloudy, of high specific gravity and will contain a large amount of albumin, casts, and frequently blood and pus. In chronic interstitial nephritis the urine is pale, clear, of low specific gravity, with only a faint trace of albumin, and greatly increased in amount, so that the patient must rise to void dur- ing the night. Frequently more is voided at night than during the day. The amount is increased because a large amount of water is voided to dilute and render the waste products less irritating. The functional efficiency of both kidneys together or each kidney separately may be tested by examining the normal con- stituents eliminated. As the diseased kidneys cannot function properly the normal constituents decrease as the abnormal in- crease. They may be tested together (1) by measuring the "in- take" of protein in the diet, the total "output" of nitrogen (pro- tein waste), and the amount of nitrogen in the blood. Speci- mens of urine and blood will then be sent to the laboratory to be examined for "total nitrogen" or "total urea"; (2) by meas- uring the "total chlorids" of the urine; (3) by measuring the intake of fluids and the output of urine; (4) by the phenolsul- phonephthalein test. The normal output of nitrogen in twenty- four hours on the usual diet is about 15 grams; the normal out- put of urea, about 30 grams; the normal output of chlorids from 10 to 15 grams. The normal "blood nitrogen" is 25 to 30 mgm. per 100 c.c of blood; the "blood urea" is from 11 to 15 mgm. per 100 c.c. of blood. In nephritis, the blood urea or nitrogen may be greatly increased and the output in the urine greatly decreased. The Phenolsulphonephthalein Test.—Principle.—Phenolsul- phonephthalein is a colorless, harmless dye which under normal conditions when injected subcutaneously is very rapidly excreted by the kidneys. The amount present in the urine voided may be determined by comparison in the colorimeter with a standard solution. When the kidneys are normal the dye usually begins to appear in the urine in from five to ten minutes, and the total excretion at the end of two hours is from 50 to 85 per cent. In elderly people confined to bed it may be only from 40 to 50 per cent. In nephritis or with a failing heart only from 5 to 10 per cent, may be excreted. Technique.—"The patient drinks a glass of wti-er and about half an hour later the bladder is emptied, either spontaneously or by catheter. Exactly 1 c.c. of the solution from an ampule is then injected subcutaneously into some part of the trunk free from edema, preferably the lumbar region, using for the purpose an accurately graduated syringe. At the end of two hours from the time of injection the patient empties the bladder again or is catheterized and the urine is collected. In some cases a catheter is placed in position when the injection is given and the urine as it trickles out is collected in a receptacle containing a few 450 THE PRINCIPLES AND PRACTICE OF NURSING drops of 10 per cent, sodium carbonate solution. The time of the first development of a pink coloration of the fluid in the receptacle is noted, as this indicates the period elapsing before the first elimination of the dye." In acid urine the dye remains colorless so that when the specimen is collected at the end of two hours, if the urine is normal in reaction there will be no change in color to indicate the presence of the dye. In the labo- ratory before making the test the urine is first made strongly alkaline with sodium carbonate solution, causing it to become more or less intensely red according to the amount present. Nephritic test diets, such as the Mosenthal, are sometimes given in chronic nephritis in which the specific gravity is low. The urine is examined, particularly to learn whether the patient, on a known, carefully regulated diet, can "concentrate his urine," that is, increase the specific gravity or the solid waste products eliminated by the kidneys. The urine is also examined for total nitrogen and chlorids. The food given is salt-free; all food and fluid is weighed or measured; all food or fluid not taken is weighed or measured so that the exact amount eaten is known; no food or fluid is given except at meal time; no food or fluid is given during the night or until eight o'clock the next morning (after voiding) when the regular diet is resumed. The patient empties the bladder at 8 A. M. and at the end of each of the following periods: 8 A. M. to 10 A. M.; 10 A. M. to 12 N.; 12 N. to 2 P. M.; 2 P. M. to 4 P. M.; 4 P. M. to 6 P. M.; 6 P. M. to 8 P. M.; 8 P. M. to 8 A. M. The specimens must be collected in properly labelled bottles. Any mishaps or irregularities that occur in giving the diet or collecting the speci- mens should be noted. The urine is examined at the intervals noted in order to gain as accurate an idea as possible of how the kidney is working. The normal kidney responds very readily to the diet given; on a high protein diet the total nitrogen in the urine will be increased and the specific gravity of the urine varies at different periods of the day, for instance, it is higher in the early morning specimen, but in advanced chronic interstitial nephritis there may be no change in the specific gravity, or in the output of nitrogen, etc., the kidneys being quite unable to elimi- nate the solid wastes. The function of each kidney may be tested separately by catheterizing the ureters and examining the urine collected from each kidney. The result may show that one kidney is perfectly normal and that the albumin and casts in the urine come from one diseased kidney. In that case the treatment may be the removal of the diseased organ. Again in a tuberculous kidney part of the kidney may be diseased, causing albumin and casts to appear in the urine, but the rest of the organ may be normal and do the work of the whole kidney efficiently. These functional tests are very important from the standpoint of diagnosis and treatment. For instance, in advanced chronic nephritis an examination of the urine for abnormal constituents THE NURSING CARE IN MEDICAL DISEASES 451 may show only a trace of albumin and an occasional cast, and yet a test of the functional efficiency may show it to be so greatly reduced that any extra strain, such as an infection elsewhere in the body or an ether anesthesia, may bring on an acute attack, possibly uremia and death. The value of all such tests depends upon the intelligence and accuracy with which nurses carry out instructions in relation to the diet and collection of urine specimens. The Nursing Care and Treatment.—Rest in bed is essential. All unnecessary exertion is to be avoided. The patient may not even be allowed to sit up because all forms of exercise mean in- creased metabolism and tissue wastes to be eliminated and the ashes formed are very irritating to the kidneys. For this reason all causes of discomfort and restlessness are particularly to be avoided. The Diet.—Rest of the kidneys is only possible through a carefully regulated diet. It is usually restricted in amount and very carefully selected. All foods which irritate or are elimi- nated with difficulty or whose ashes increase the work of the kidney are to be avoided. Starvation is also avoided as it results in destruction of muscle and other body tissues, the ashes of which are irritating and increase the work of the kidneys. Pro- tein is restricted to an amount barely to meet the body needs. Salt may also be restricted to either a "salt-poor" or "salt-free" diet. Salts are restricted particularly in edema. Sometimes milk alone is given because it is low in sodium chlorid. It contains sugar and fat (cream may be added) and sufficient protein to meet the body needs may be given in this way. Fruits contain very little salt so are freely given. Sugar and fats leave little waste for the kidney to eliminate. They increase the cal- oric value and prevent tissue destruction, so are usually allowed. Foods which irritate, such as celery, onions, radishes, garlic and condiments are to be avoided. Meat extracts and broths are also avoided. They have little nutritive value and contain sodium chlorid, pigments, creatinin, etc, irritating to the kidneys. Fluids.—When the kidneys are able to eliminate and the pa- tient is not edematous, fluids are usually forced, to dilute the waste products, flush them from the system, and lessen irritation of the kidneys. Water, lemonade, orangeade, and imperial drink are given by mouth. Water is also given by rectum by means of colon irrigations or the Murphy drip. Where the patient is edematous, and in anuria, showing the kidneys to be impermeable to water, fluids are restricted and elimination through other chan- nels is encouraged. Thirst which usually results may be relieved by ice or water in small amounts. The care of the mouth is very important. The amount of fluid, or the "intake," should be carefully measured and charted. The fact that this restricted diet, especially the craving for salt and water, is apt to make the patient unhappy, irritable and depressed, must be constantly in the mind of the nurse. 452 THE PRINCIPLES AND PRACTICE OF NURSING The condition of the skin is of vital importance. We rely on the skin to save the kidneys. It must be kept warm and its circulation and functions stimulated. Rest in bed between blan- kets, daily cleansing baths and massage aid greatly. Chilling must be avoided. It prevents perspiration and causes increased congestion of the kidneys and other organs by driving the blood from the skin. It contracts the blood vessels and raises the blood-pressure, so is particularly harmful when the pressure is already high. Shivering is injurious. It means increased mus- cular activity and wastes to be eliminated. All exposure to cold air or water is to be avoided. Fresh air without exposure is desirable. The care of the skin is also important because of the danger of bedsores. The disease is prolonged and the patient is con- fined to bed. He becomes pale and anemic from the constant loss of albumin and from confinement. He either loses weight and becomes emaciated or his tissues are edematous. Some- times he is obliged to sit up constantly (condition of orthopnea) and in any case his movements are restricted. All these condi- tions predispose to bedsores and demand the best nursing care to prevent them. The Body Eliminations.—To rest the kidneys, elimination through all other channels is stimulated. As stated above, the circulation and functions of the skin are stimulated. When water is allowed fluids are forced to stimulate perspiration. Hot fluids are good. Hot baths, hot packs, and drugs (diaphoretics) are used for the same purpose. Heat relaxes the arteries and lowers the blood-pressure. Sweating is stimulated, particularly when there is edema. With a good sweat it is said that one quart of water and fifteen grains or more each of urea and sodium chlorid may be eliminated. When the blood-pressure is high with arteriosclerosis and a hypertrophied heart extreme care must be taken in giving hot packs because of their depressing effect on the heart and nervous system, etc. The bowels are kept open and stimulated by the use of cathar- tics which cause watery movements, especially with edema. Elimination by the kidneys themselves is stimulated by forced fluids, by mouth or rectum, and by local applications of counter- irritants—stupes, mustard pastes and dry cupping, etc These relieve inflammation and congestion, pain and suppression. Hot colon irrigations not only supply fluid, but as the hot fluid cir- culates in the colon it is in close contact with the kidneys and is an internal application of heat. Alkaline diuretics, such as sodium citrate and potassium acetate, are given, but those which irritate, such as caffeine and diuretin, are avoided. The Avoidance of Infection.—Infections such as colds, ton- sillitis, ulcerated teeth, and all other infectious diseases should be avoided. When the kidneys are diseased their resistance is lowered so that they are very susceptible to infection by germs as they are being eliminated. THE NURSING CARE IN MEDICAL DISEASES 453 The Relief of Symptoms.—Headache is relieved by increasing the eliminations, by local applications of heat or cold and by the administration of such drugs as phenacetin or antipyrin. Backache and suppression are relieved by the local applica- tions mentioned above which relieve inflammation and conges- tion. Massage of the lumbar region also helps. Edema is relieved by restricting salts and fluids, and by stimu- lation of the elimination of wastes through all channels. Fluid from the abdominal cavity (ascites), the pleural or pericardial sacs may have to be withdrawn by aspiration. Dyspnea may be very distressing due to an hypertrophied heart or fluid in the pericardial, pleural or abdominal cavities. The nursing care is extremely important. The patient is usually obliged to sit up constantly; the weight of the edematous limbs and accumulated fluid make moving difficult; breathing is diffi- cult; he is usually unable to sleep, and altogether, he is apt to be extremely uncomfortable, unhappy and a burden to himself. Shortness of breath, cyanosis, and a weak pulse are very grave symptoms in this disease. A High Blood-Pressure.—For the treatment see diseases of the blood vessels. Special care must be taken when giving hot packs—watch for weakness, fainting and palpitation. Anemia.—The patient becomes' pale and pasty in color due to the continued loss of albumin and confinement in bed, etc Iron and foods rich in iron are usually given. Sunlight and fresh air (without exposure) are beneficial for the anemia as well as the depressed frame of mind. Uremia.—As uremia is due to toxemia caused by failure of the kidneys to excrete, the treatment is that given for nephritis. A lavage may be given if nausea and vomiting occur. Chloral is usually given if convulsions occur. Morphin is not given, as the respiratory center is already depressed by the toxemia, shown by the Cheyne-Stokes respirations usually present. Urinalysis.—Tests for Albumin.—A nurse, at least in a private home, in taking care of a patient suffering with nephritis, or a disease in which nephritis may develop as a complication, may be required to test the urine for albumin. A nurse engaged in public health work or in visiting nursing or in a doctor's office may also be required to do simple urine tests. The following are simple tests for albumin which may be used. 1. Heat and Acetic Acid Test.—Fill a test tube two-thirds full of urine. Add about five drops of 2 per cent, acetic acid (enough to make the reaction acid), and boil at the top, holding the tube at the bottom and directing the flame against the upper portion of fluid. Add a few more drops of acid, then examine the tubes by transmitted light against a black background for a cloud in the top portion as compared with the portion just below it. If the precipitate is flocculent, take the tube in a holder and heat the entire contents to boiling and stand the tube in a rack. When the precipitate has settled, fifteen minutes or 454 THE PRINCIPLES AND PRACTICE OF NURSING more afterward, mark the percentage of albumin according to the estimated proportion of the column of urine occupied by the sediment. The result may be reported as "v. f. tr." (very faint trace). "f. tr." (faint trace). "tr." (trace). "m. tr." (marked trace). "v. m. tr." (very marked trace). 2. Coagulation of Albumin by Concentrated Nitric Acid.— Pour about 2 c.c. (one-half dram) of nitric acid into a test tube. Then an equal volume of urine is allowed to flow in slowly so as to form a layer above the heavier acid. A white ring at the junction of the fluids indicates the presence of albumin. These lests are based upon the fact that albumin is coagulated either by heat or strong acids. Test for Blood.—Guaiac Test.—To about 4 c.c. of urine add 1 c.c. of glacial acetic acid and 2 c.c. of ether; shake gently; pour off the ether, and add a few drops of freshly prepared guaiac tincture and 1 c.c. of hydrogen peroxid. Never use a test tube with yellow copper oxid on its walls resulting from Fehling's or Benedict's sugar test. A blue color indicates the presence of blood.1 THE NURSING CARE IN DIABETES MELLITUS Diabetes is a disturbance of metabolism due to the partial or total inability of the tissues to burn carbohydrates. As the blood normally carries only 100 to 120 mgm. of sugar to 100 c.c. of blood, or 0.07 to 0.11 or 0.1 per cent, of sugar, when not burned the excess overflows into the urine. Diabetes is due to no fault or disease of the tissues, but to the absence of some agent which will combine with the sugar and make it available to the tissues. It is as though a match or spark were needed to ignite the sugar just as coal or wood, etc., must be ignited before it will burn in the furnace. This agent, which is deficient or absent, is thought to be the internal secretion of the islands of Langerhans in the pancreas. The Nursing Care and Treatment.—As the disease is incur- able, the treatment is directed toward prolonging the life of the patient as many years as possible and providing the greatest degree of happiness, usefulness and comfort. The doctor pre- scribes the treatment, which the nurse must see is carried out with the most scrupulous care and intelligence. The nursing care is extremely important, for the regulation, preparation, and serving of the diet, together with personal hygiene, are the great and all-important factors. Again, in diabetes particularly, the nurse must remember her duties as a teacher, for "the patient is at school to learn how to save his life." As the disease lasts "St. Luke's Hospital Laboratory Technique. THE NURSING CARE IN MEDICAL DISEASES 455 throughout the life of the patient he must be taught how to take care of himself. "Give them to understand that they are at school rather than at a hospital." The treatment—restriction of the diet and normal habits of living—will depend somewhat on whether the patient is suffer- ing from the disease in a mild, moderate, or severe form. This is determined by regulations in the diet, examinations of the urine and blood, and by the general symptoms and progress of the disease. The disease is said to be mild, when the patient's tolerance for sugar is less than normal, but the urine can be made sugar-free by simply cutting down the total diet or by eating less carbohydrates; moderate, when the tolerance is still lower, but the urine can be made sugar-free by eating still less and cutting down the amount of fat, protein and carbohydrates; severe, when the patient cannot tolerate any carbohydrates with- out sugar appearing in the urine; sugar may appear even on a "carbohydrate-free" diet or even in fasting or starvation. In all, the following factors must be considered: The Diet.—The life of the patient depends upon a proper regulation of the diet. Just as it is the province of the doctor, only, to prescribe drugs and other treatments, so it is the doctor, only, who should prescribe the diet for a diabetic patient. The nurse is there to see that, within the limits prescribed, the best selection is made; to avoid errors; to see that the food is prop- erly prepared in the most digestible and acceptable form; for instance, while fat may be prescribed, foods fried in fat should never be given. She is there to see that the food is promptly and attractively served; to see that the restrictions and limita- tions cause as little distress as possible; that the tastes of the patient and variety are considered as far as the limitations per- mit ; that the patient eats slowly and chews the food thoroughly; that the meals are as well balanced and resemble as nearly as possible the diet of a normal person for breakfast, dinner and supper. She must also watch closely the effect of the diet on her patient. In order to get the best results, to avoid errors, to gain the co-operation of the patient and to teach him how to plan and prepare his diet, the nurse must understand the following prin- ciples which guide the doctor in regulating the diet: The aim is to make the urine sugar-free, to increase the carbo- hydrate tolerance, to prevent progressive loss of weight (except in obesity and overweight), and to do so without the appearance of the dreaded acid intoxication. The body of a normal person has a limit to its ability to use glucose and tolerates it up to a certain point; beyond that it overflows into the urine. In diabetes this limit or tolerance for sugar and starches is more or less reduced according to the severity of the disease. It is most important to find out just what this tolerance is, that is, how much sugar or starches may be given without sugar appearing in the urine. Sugar in the 456 THE PRINCIPLES AND PRACTICE OF NURSING urine may be due not only to carbohydrates given in the diet, but also to those stored in the body, in the muscles and liver, etc Sugar may also be formed from protein given in the diet or from the body tissues. Again sugar in the urine may be due to over- eating (irrespective of the kind of diet), which so overworks, hampers and clogs the body that its power to assimilate carbo- hydrate is lessened. The urine may be made sugar-free and the tolerance for carbohydrates may be increased by resting the pancreas, that is, resting the function of assimilation. This may be accomplished by restricting the total diet, or by cutting down the carbohydrate and protein or by complete fasting until the urine is sugar-free. Each day the urine remains sugar-free in- creases the tolerance, whereas if the patient is untreated, the tolerance is lowered. The sudden reduction of carbohydrates and protein or fasting may, however, lead to very serious results, that is, to acidosis and coma. For the body simply must have fuel. If it cannot utilize carbohydrates it will use fat as the next best fuel. But without carbohydrates fats cannot be completely burned, for "fats must be burned in the flame of carbohydrates." Incomplete burning of fatty acids causes acidosis, acidosis causes coma, and coma death. Acidosis is indicated by the presence of acetone, diacetic or (3-oxybutyric acid in the urine and by other symptoms to be mentioned later. Protein is also a contributing factor in acidosis. In restricting the diet, therefore (usually in all, but particularly in the severe cases), fat is the first article cut down in order to avoid the possible danger of acidosis. When, by restrictions in the diet, the urine has become sugar-free, the next step is to find the carbohydrate tolerance by gradually increasing the daily amount, then the protein tolerance or both may be tested to- gether. Last of all fat is added. Twenty-four-hour specimens of urine are daily examined for sugar, acetone, diacetic and (3-oxybutyric acid. The blood is also examined for sugar because an increase in the blood-sugar may appear before sugar in the urine. The test is always made before breakfast because the blood-sugar rises after meals. These examinations determine whether the diet may be increased or not. It is one of the nurse's most important duties to see that no errors occur in the collection of specimens. In building up a diet that the patient can tolerate, in addition to the amount of carbohydrate, protein and fat, strict attention is given to the total number of calories. If too high it will cause sugar to appear in the urine. On the other hand, the body (ac- cording to the age and weight) even when quietly at rest in bed must have sufficient calories to carry on the activities which mean life and prevent progressive loss of weight. Even when the fat allowed is high and excess protein is given sufficient to supply material for building and repair and also for the pro- duction of energy, the total calories allowed may be pitiably small because of the great restriction in carbohydrates. In the THE NURSING CARE IN MEDICAL DISEASES 457 diet of the normal individual more than half of the energy comes from carbohydrates. CALORIES REQUIRED DURING TWENTY-FOUR HOURS BY AN ADULT WEIGHING SEVENTY KILOGRAMS (ONE HUNDRED AND FIFTY-FOUR POUNDS).1 Calories Per Kilogram, Calories Body Per Pound, Total Condition. Weight. Body Weight. Calories. At rest ............. 25 to 30 11 to 14 1750 to 2100 At light work ....... 35 to 40 16 to 18 2450 to 2800 At moderate work ... 40 to 45 18 to 20 2800 to 3150 At hard work....... 45 to 60 20 to 27 3150 to 4200 "Children require far more food than adults, because of growth and increased activity." THE CARBOHYDRATE, PROTEIN AND FAT IN THE DIET OF A MAN DOING MODERATE WORK, WEIGHT SEVENTY KILOGRAMS (ONE HUNDRED AND FIFTY-FOUR POUNDS)1 Quantity Calories Total Food. Grams. Per Gram. Calories. Carbohydrate........... 400 4 1600 Protein ................ 100 4 400 Fat .................... 100 9 900 A nurse must therefore not only note the amount of the various foods in the diet and the effect upon the patient, but also the total calories in the diet, and see that the energy provided is conserved for the necessary body activities. For instance, when the diet is low calories must not be wasted by overexertion or exposure to cold; cold water or ice cream (even though made in accordance with the diet allowed) should not be given because calories would have to be used in warming them. Conservation of energy is particularly important in old people. For this rea- son, fasting is usually avoided. Fluids.—Diabetic patients are always thirsty. They must have water to excrete the sugar, and in acidosis, the acids, in the urine. Water, tea, coffee and clear meat broths are the usual fluids allowed. Broths must be properly seasoned; salt is good for diabetes. Hot drinks are always best because they avoid the loss of calories otherwise needed in warming them. (It must be remembered that the large amount of urine voided [at body temperature] robs the body of heat.) Warm fluids are given during the period of fasting. It may be necessary to 1 Joslin. 458 THE PRINCIPLES AND PRACTICE OF NURSING give increased amounts (if the amount of urine voided is less than normal) in order to remove acids and prevent acidosis. Rest and Exercise.—Plenty of sleep and rest are essential in all cases. Overexertion and fatigue are to be avoided; fatigue raises the blood sugar. Exercise in some form, however, is always desirable. It keeps the muscles in good condition, im- proves the circulation, metabolism, mental attitude and general health. By exercising, the carbohydrate tolerance is often in- creased without sugar appearing in the urine. "If the patient, by means of exercise, can have 5 grams more of carbohydrate a day the added comfort will be enormous, for the addition of 5 grams of carbohydrate to a diet in a case of severe diabetes brings almost untold joy." It allows for much greater variety and helps to prevent loss of weight. Out-door exercises and those which are enjoyable and diverting give the best results. Exercise should be moderate with periods of rest following. The amount allowed depends upon the condition and the total calories in the diet. In severe cases overexertion may predispose to coma. Massage is valuable. The amount of exercise may be increased by training. Mental Hygiene.—There seems to be an important relation between diabetes and the nervous system. It sometimes dates from a severe mental strain or nervous shock. The disease itself has a very depressing effect on the mind—the patient is apt to be morose, complaining, anxious, with a tendency to cry easily and to be upset by trivial things. The ravenous appetite, the in- tense craving for sweets, and starches, and the restricted diet also make him very unhappy. His conscience may be so affected that he will lie or steal to get food the body so intensely craves. These patients are not entirely responsible for their actions or mental attitude. A normal person finds it hard to be patient, sweet-tempered and uncomplaining when the appetite is dissatis- fied; how much harder must it be for the person whose will, self- control and courage are already shattered by disease? The fact that the disease is not curable is also depressing, but the patient should be cheered by the feeling that he has much to be thankful for in that the disease is painless, clean, and not unsightly like many others, and that he himself can control it by strictly fol- lowing the doctor's orders. Quiet, freedom from worry, emo- tional strain, mental excitement, or fatigue are essential. Any nervous strain predisposes to coma. "It is dangerous to get angry." Arteriosclerosis is usually present in diabetes, particu- larly in the severe forms and greatly adds to the danger of nervous strain (see arteriosclerosis). Sleep and mental diversion such as reading, writing, games, conversation with friends and work which does not cause fatigue are valuable. A nurse should interpret complaining-and ingratitude, etc, chiefly as symptoms of the disease and should welcome a more cheerful attitude as a sign of improvement in the patient's con- dition. THE NURSING CARE IN MEDICAL DISEASES 459 Care of the Skin.—It is extremely important to keep the skin in good condition, active, clean, warm, free from irritation, slight wounds, infections, bed-sores, or gangrene. It is apt to be dry and harsh due to loss of water in the urine. Its function is inter- fered with, metabolism in the tissues is poor and diabetics are very susceptible to infections such as boils and carbuncles, etc. Intolerable itching and eczema sometimes occur. The urine is irritating and may cause pruritus. Increased blood-sugar causes arteriosclerosis and this may cause many of the capillaries to disappear so that the tissues are poorly nourished; bedsores and gangrene may result. Emaciation adds to the danger of bed- sores. Any break in the skin heals with great difficulty. It must be kept scrupulously clean by daily baths and its function stimu- lated by warmth, exercise, massage and by giving plenty of water to drink. Gangrene may be prevented by avoiding con- ditions which lead to arteriosclerosis, and by improving the cir- culation, especially of the extremities. Care of the Mouth and Teeth is also most important. The mouth is usually dry; thirst is distressing. The tongue is dry, red and glazed. The gums may be swollen. Stomatitis some- times occurs. The teeth are often in poor condition, which in- creases the severity of the diabetes. The mouth always harbors germs and, as before stated, diabetics are very susceptible to infections and frequently die from complications such as tuber- culosis, lobar or bronchopneumonia. All infections—colds, ton- sillitis, influenza, boils, etc—favor the onset of coma, lower the carbohydrate tolerance, and interfere with the treatment of the diabetes. In tuberculosis, for instance, the diet is increased and overweight is desirable; in diabetes the diet and weight are always kept slightly below normal. The patient should never be exposed to infection, but particularly when on a low diet. Diabetes always grows worse with infection. A nurse with a cold should not take care of a patient with diabetes. The Body Eliminations.—The bowels must be kept open. Constipation is common and predisposes to coma. The function of the skin and kidneys must be kept active. Symptoms to be Watched For and Reported.—Symptoms of Coma.—Patients who die of diabetes die in coma. Coma may usually be prevented if the early symptoms are noted and re- lieved. It is very difficult to cure once developed. As stated previously, it is due to acid intoxication resulting from the faulty metabolism of fat, and also, some think, of protein. The onset may be favored by various factors which are therefore to be avoided. These may be an ether anesthesia, impaired function of the kidneys and failure to eliminate the fatty acids, constipation, mental excitement, infections, fatigue, exposure and chilling, overeating, fasting, sudden changes in the diet, im- proper regulation of the diet, such as cutting down the carbohy- drates only or a sudden increase in the fats with a low carbo- hydrate diet for without carbohydrates fats cannot be burned. 460 THE PRINCIPLES AND PRACTICE OF NURSING "With an excess of fat diabetes begins and from an excess of fat diabetics die." The Symptoms.—Dyspnea, diabetic air-hunger, in which the breaths are deep and straining, is one of the most important. It is an effort of the body to get rid of carbon dioxid or carbonic acid in order to lessen the acidity and keep the reaction of the blood normal. Other symptoms are loss of appetite, nausea, vomiting, headache, listlessness, drowsiness, weakness, vertigo, ringing in the ears, disturbance of vision, excitement or delirium. The blood will show an increased percentage of fat. The urine will show the presence of (3-oxybutyric acid or diacetic acid or acetone, both of which are derived from the former. (3-oxy- butyric acid indicates diabetes in the most severe form. The treatment consists in avoiding the conditions which pre- dispose to or deepen the coma. Liquids are given freely by mouth, by rectum and sometimes intravenously. A solution of glucose is sometimes given by rectum to supply fuel and prevent the combustion of body fats. When given in this way it is slowly absorbed and oxidized so that the tissues can handle it more easily. Some doctors give a solution of bicarbonate of soda by rectum or intravenously to neutralize the acidity of the blood —other doctors consider this harmful. Symptoms of Complications, which are apt to occur and from which the patient may die, should be recognized immediately. The most common complications are pneumonia, tuberculosis, nephritis, boils, carbuncles, abscesses, pruritus and gangrene. Urine Tests in Diabetes.—A nurse in a private home, when caring for a patient suffering from diabetes or when engaged in public health work, visiting nursing, or in a doctor's office, may be required to examine the urine for sugar, acetone, diacetic or (3-oxybutyric acids. The following simple tests may be used: Tests for Sugar.—1. Fehling's Test.—Put about 3 c.c. of urine in a test tube. Add about 5 c.c of boiling Fehling's solu- tion, then boil the mixture and place the tube in the rack. The formation of a typical red or golden yellow precipitate indicates the presence of sugar. 2. Benedict's Test.—Put 5 c.c of the reagent and eight drops of urine in a test tube. Immerse the tube in a water bath of boiling water and keep the water boiling. At the end of exactly five minutes remove the tube and allow it to cool. If the fluid becomes opaque, it indicates that sugar is present. If no sugar is present the fluid remains clear or only a faint turbidity results due to urates. These tests are based upon the fact that sugar is a reducing agent, that is, it will precipitate or separate heavy metals from their compounds. Fehling's solution, for instance, is a compound containing copper, which when precipitated gives the usual cop- per color to the solution. The Benedict test is a more sensitive one than Fehling's because the reagent is not reduced by uric acid, creatinin, and other substances which are in the urine as Fehling's solution may be. THE NURSING CARE IN MEDICAL DISEASES 461 Test for Acetone.—Drop a crystal of sodium nitroprusside in 5 to 10 c.c. of water. Add 1 to 2 c.c. of this solution and a few drops of glacial acetic acid to 5 c.c. of urine and stratify strong ammonia over the mixture. A purple ring at the junction of the fluids indicates that acetone is present. Test for Diacetic Acid.—Add a few drops of 10 per cent. ferric chlorid to about 10 c.c. of urine, drop by drop. If a pre- cipitate forms, filter and add a few more drops of ferric chlorid. A "Burgundy" red indicates that diacetic acid is present. If the patient has been taking phenol, salicylates, aspirin, acetanilid or antipyrin, a dark color will also be produced on the addition of ferric chlorid to the urine, but it will be a purple rather than a red as when due to diacetic acid.1 MEDICAL EMERGENCIES Syncope.—The word syncope comes from a Greek word, synkope, which means a cutting short, a swoon or fainting. It is a condition of more or less complete unconsciousness due to anemia of the brain resulting from a sudden fall of blood-pres- sure or failure of the heart to maintain the circulation. The causes of the cerebral anemia may be:— 1. Lowered blood-pressure from the actual loss of blood as in a hemorrhage. 2. Lowered blood-pressure from a weakened heart action which fails to maintain the circulation and allows the blood to accumulate in the veins. This is called "bleeding into the veins" and is the condition of the circulation after death, the venous system being so large that it will contain, when completely re- laxed, all the blood in the body. The effect on the heart, brain, and body tissues is the same as when blood is actually lost. The weakened heart action may be the result of heart disease or of some temporary weakness resulting from depression of the nervous system as from the action of drugs, or fear, or worry, etc., or from physical exhaustion as from hunger, overexertion, or slight exertion when in a weakened condition. Fainting, as a result of a sudden change in position from the recumbent to the upright, when the nervous system is depressed, as in jumping out of bed when half-awake, or in the old in whom the circu- lation is not readily adjusted has already been mentioned in an earlier chapter. 3. The lowered blood-pressure and weakened heart action may be due to stimulation of the vasomotor center resulting in a marked change in the distribution of blood in the three great reservoirs of the body—the skin, intestines, and muscles. In fainting, the skin is blanched and the body surface is cold be- cause the blood vessels of the skin (and of the intestine) are contracted and the blood is driven into the dilated vessels of *St. Luke's Hospital Laboratory Technique. 462 THE PRINCIPLES AND PRACTICE OF NURSING the muscles. It is stated (Brunton) that the blood vessels of the muscles are large enough to allow as much blood to pass through them, in a given time, as through the vessels of the skin and intestines together. This rapid passage of blood from the art- eries to the veins lowers the blood-pressure. Anemia of the brain follows. This explains fainting as the result of severe pain, fright, joy, the sight of blood, or of an accident, all of which directly or reflexly stimulate the vasomotor center. The Symptoms.—A feeling of weakness and dizziness with roaring in the ears may precede the attack or the patient may suddenly feel weak and fall, unconscious, to the ground. The face and lips are blanched, the eyes are closed, the body surface is cold and clammy, the muscles are completely relaxed, the pulse is weak and small, and the respirations are shallow. The Treatment.—In most cases merely lowering the head be- tween the knees or placing the patient flat on his back with the head low, will prevent an attack or revive a patient. Fresh air should be admitted freely to the patient and all clothing should be loosened about the neck, chest, and waist. The respirations may be stimulated reflexly by giving inhalations of smelling salts or ammonia, by sponging or dashing cold water over the face and chest, or by friction to the chest with the hand moist- ened in cold water, or by slapping the chest smartly with the hands or end of a cold wet towel. Heat applied for a brief period over the heart will increase the force and rate of the heart beat and stimulate the circulation. Heat applied to the neck, head and face will increase the supply of blood in the head and excite the mental activities. When consciousness is regained and the patient is able to swallow, water, aromatic spirits of ammonia, whisky, or a hot drink should be given. After an attack of syncope, the patient should not attempt to sit up or walk about, but should lie quiet and at rest until the circulation is re-established. Collapse.—The pathology, symptoms and treatment of col- lapse are the same as in shock. The conditions are identical but the term collapse is usually used when the prostration is the re- sult of disease whereas the term shock is used when it is the re- sult of a surgical condition such as an accident or operation (See shock, Chapter XXXII.) Asphyxia.—The word asphyxia comes from the Greek prefix, a, meaning an absence of, and sphyxis, meaning pulse. It is a condition of unconsciousness due to suffocation or interference of any kind with the oxygenation of the blood. The causes of asphyxia may be:— 1. Mechanical interference with the entrance of air to the lungs which may be (1) inflammation and swelling of the throat and larynx or the formation of a membrane as in diphtheria; (2) edema of the glottis in diphtheria, tuberculous laryngitis, THE NURSING CARE IN MEDICAL DISEASES 463 cardiac and renal diseases; (3) foreign bodies in the respiratory tract; (4) pressure on the trachea or bronchi from goitre, tumor or aneurysm; (5) water and mucus, etc., in the respiratory tract as in drowning. 2. The inhalation of smoke, or poisonous gases such as coal- gas or illuminating gas, or the fumes of ammonia, or nitric acid, or the inhalation of ether in a general anesthetic. 3. Interference with the interchange of gases between the blood and air in the lungs as in diseases of the heart or lungs, and in poisoning from carbon monoxid in which the hemoglobin is saturated with the gas and cannot combine with oxygen. 4. Weakness of the respiratory muscles, or convulsive spasms as in croup or whooping-cough, or paralysis as in diseases or in- juries involving the upper part of the spinal cord. 5. Weakness of the respiratory center in the medulla. The work of the respiratory center (and other centers in the medulla) depends upon the amount and character of the blood flowing through it. It is stimulated by venous blood. 6. Failure of the lungs to expand in the new-born. The symptoms of asphyxia develop in three stages:—In the first stage, the venous blood flowing through the medulla stimu- lates the respiratory center, making the breathing more rapid (hyperpnea), labored (dyspnea), and distinctly audible. Res- piratory muscles not used in quiet breathing are forced into action. The appearance of the patient is alarming—the lips are blue, the face congested, the eyes prominent and bloodshot and the expression is anxious. The venous blood also stimulates the vasomotor centre so that the blood pressure is raised owing to the contraction of the peripheral blood vessels. This stage lasts about one minute. The second stage is the stage of convulsions due to the further stimulation of the centers in the medulla by the venous blood. This stage lasts less than one minute. The third stage is the stage of exhaustion. The patient be- comes unconscious, the muscles flaccid and the pupils widely di- lated. The blood-pressure falls and the pulse is almost imper- ceptible due to heart failure. The inspirations are prolonged and sighing and the intervals between increase until breathing finally ceases. Death results from gradual exhaustion and pa- ralysis of the centers in the medulla from the prolonged action of the venous blood. The third stage may last three minutes or more. After death the veins are found engorged and the arteries empty. The Treatment.—The first step is to remove, if possible, any obstruction to the free passage of air. If the obstruction is due to fluid in the lungs and bronchi, as in drowning, the patient's clothing should be loosened about the neck, chest, and waist, and he should then be turned on his face, and his body raised at the waist-line by means of a folded blanket or clothing. Pressure 464 THE PRINCIPLES AND PRACTICE OF NURSING should then be applied, with both hands spread out, upon the lower chest wall to expel water from the stomach and lungs, and to allow it to run out by gravity from the trachea and mouth. The nose, mouth and throat should be cleansed of mucus. In all cases of asphyxia, the treatment consists in removing anything which might interfere with breathing, in establishing natural respiration with the least possible delay, and in treat- B Fig. 122.—Artificial Respirations: The Two Principal Positions, A and B, in Performing Schafer's Method. (From Halliburton's "Handbook of Physiology," Blakiston and Son, Publishers.) ing the patient for shock. He should be kept warm and should have plenty of fresh air. His clothing should be loosened about the throat, chest, and waist, and his position must be such as to keep the air passages wide open for the admission of air (see care of the patient under a general anesthesia), and to allow for the free expansion of the lungs. Foreign bodies (such as false teeth) or mucus should be removed from the mouth or throat. Artificial respirations should be begun without delay. THE NURSING CARE IN MEDICAL DISEASES 465 Artificial Respirations,—There are several methods of giving artificial respirations (that is, starting up respiration in a person in whom it has ceased) among which are the Sylvester, Schafer, Laborde, Howard, and Marshal Hall methods. A nurse should become familiar with one or more methods and should practice giving them. Speed in action and perseverance are essential. Two methods commonly used are the Schafer and the Sylvester methods. The Schafer or the "prone-posture method" saves labor and is said to be the simplest, most effective, and least injurious. The method is best described in the words of the author, as fol- Fig. 123.—Artificial Respirations. Sylvester's method. Inspiration (Da- Costa). (From Owen's "Treatment of Emergencies," W. B. Saunders Co., Publishers.) lows:—"It consists in laying the subject in the prone posture, preferably on the ground, with a thick folded garment under- neath the chest and epigastrium. The operator puts himself athwart or at the side of the subject, facing his head, and places his hands on each side over the lower part of the back (lowest ribs). He then slowly throws the weight of his body forward to bear upon his own arms, and thus presses upon the thorax of the subject and forces air out of the lungs. This being effected, he gradually relaxes the pressure by bringing his own body up again to a more erect position, but without moving the hands." The movements are repeated regularly at a rate of twelve to fifteen times a minute until normal breathing begins or until the possibility of its restoration is abandoned. Efforts to revive the patient should be continued for an hour or more. 466 THE PRINCIPLES AND PRACTICE OF NURSING The Sylvester method, frequently used, consists in loosening the clothing, removing mucus or foreign bodies from the mouth or throat and placing the patient flat on his back with a pillow or folded blanket between the shoulders so as to raise the chest, extend the trachea, throw the head back and keep the air-pas- sages open. The tongue should be grasped and held well for- ward by an assistant. The operator kneels at the head facing the feet of the patient and, grasping both elbows, moves the arms slowly outward from the body and upward above the head as far as they will go. This causes the expansion of the chest or inspiration. The arms are held in this position for a few seconds then brought toward each other, then downward to their original position against the floating ribs, making pressure upon them so Fig. 124.—Artificial Respirations. Sylvester's method. Expiration (Da- Costa). (From Owen's "Treatment of Emergencies," W. B. Saunders Co., Publishers.) as to cause the expulsion of the air or expiration. These move- ments are repeated at the rate of normal respiration and efforts to revive the patient should be continued for an hour or more. Laborde's method consists in applying rhythmic and forcible traction to the tongue. The object is, through stimulation of sensory nerves in the tongue, to reflexly stimulate the phrenic nerve and thus cause contractions of the diaphragm and thereby establish voluntary respirations. In this method the tongue is grasped with forceps (or with the fingers after wrapping gauze around the tongue to keep it from slipping) and is pulled well forward and upward from ten to fourteen times a minute until voluntary respiration is established. This method is particularly valuable when an injury to the chest, arms, or shoulders prevents the use of the Schafer or Syl- vester methods. Any patient requiring artificial respirations is in a serious con- dition and is suffering more or less from shock for which treat- THE NURSING CARE IN MEDICAL DISEASES 467 ment will be required. In cases of drowning, particularly, the patient will be suffering from shock due to cold and prolonged exposure, exhaustion and fear of death. As soon as breathing has been established, the wet clothing should be removed and the patient wrapped in dry, warm blan- kets. Heat should be applied to the extremities and friction with a warm towel to stimulate the circulation. Whiskey or brandy may be given by rectum, stimulants may be given by hypodermic, and heat or a mustard paste may be applied over the heart to stimulate the heart and circulation. As soon as he is able to swallow, hot coffee, whiskey or brandy may be given by mouth. The patient should be kept quiet and in bed until fully re- covered. The pulmotor and lungmotor are mechanical devices used in giving artificial respiration. They are used by a doctor only, so need not be discussed here. Sunstroke or insolation results from exposure, especially of the head and neck, to the direct rays of the sun. The sun's rays have a powerful effect on the body, elevating the body temperature and acting as a powerful excitant to the brain and all nerve centers. Marked congestion and swelling of the face, scalp, meninges, and brain occur. Some authorities think that the attack is due to the direct effect of the heat rays of the sun on the nerve centers while other authorities believe the attack to be the result of the action of the chemical or violet and ultra-violet rays which penetrate the skull. The symptoms are violent headache, mental excitement which may become maniacal, convulsions, and loss of consciousness. The attack may prove fatal or, if the patient recovers there may be permanent impairment of the mind with loss of memory or power to concentrate, together with other nervous disturbances, and inability to stand exposure to heat. Heat-stroke differs from the above in that the person need not be exposed to the direct rays of the sun. It results from ex- posure of the body to a high external temperature from any source, especially when the air is saturated with moisture. It may occur at midnight or in a close, poorly ventilated room. The condition is more apt to develop in debilitated persons or in per- sons engaged in hard physical labor, especially in those who are in the habit of drinking beer or whiskey, and whose clothing does not allow for sufficient heat elimination by the rapid evapo- ration of moisture from the skin. The symptoms, as described by Dr. W. G. McCallum, are as follows:— "The mildest effect (heat prostration) consists in headache, moderate rise in temperature, pains in back and limbs, and ex- treme exhaustion. More severe is the asphyctic form, in which great dyspnea and cyanosis, with delirium or unconsciousness are added to these symptoms. Still more severe, and frequently fatal, is the hyperpyretic type, in which unconsciousness and 468 THE PRINCIPLES AND PRACTICE OF NURSING collapse come on suddenly, or after several days of vague pre- monitory symptoms. There are convulsions, delirium, or pro- found coma with shallow and gasping or very deep respiration, and finally failure and stoppage of the heart. The skin, at first covered with sweat, becomes hot and dry, and the temperature rises to phenomenal levels." Cases are reported having a tem- perature of 108° to 112° F. and even as high as 117.6° F. It is thought that the extreme hyperpyrexia or thermic fever, in the above condition, is due to the impairment or paralysis of the heat-regulating centers in the medulla and that this paraly- sis, together with the failure of the heart and respiration, are the result of overheating from the extreme external heat on the nerve centers in the medulla. As a result of this paralysis, heat rap- idly accumulates in the body with no adequate provision made for its elimination. The treatment in the above conditions consists in lowering the body temperature by increasing heat elimination and preventing further heat production. The patient should be removed to a quiet, cool place and placed in bed in the recumbent position as soon as possible. His head should be slightly elevated. His clothing should be loos- ened and entirely removed. Cold applications should be applied continuously to the head and neck, in the form of compresses or an ice-bag, etc, and to the entire body in the form of cold sponges, affusions, baths or packs. Brisk rubbing should be applied so as to bring the hot blood to the skin. Cool enemata may also be given. The treatments are continued until the temperature drops to 101° F., after which the patient lies quietly in bed, covered with a sheet only. In giving the treatments, care is taken not to cause the temperature to fall below normal and cause collapse. The pulse must be closely watched through- out for symptoms of collapse. When the cold applications are removed, the patient's tem- perature must be watched constantly as it is likely to rise again rapidly and the treatments will have to be resumed. In addition to the above treatment, the early removal of blood by bleeding followed by an intravenous injection of hot normal saline may be necessary in persons in whom the pulse is bounding and the face cyanotic. Even after the temperature has been permanently reduced, the patient requires extreme care on account of the danger of cere- bral congestion, meningitis and secondary changes and impair- ment of the functions of the brain which may follow. An ice- cap should be kept on the head. Rest, quiet, fresh air, and care- ful regulation of the diet and body eliminations are essential. Exposure to the sun or any form of heat should in future be avoided as one attack predisposes to another. Heat Exhaustion differs from the above, in that, while it may be produced by the same conditions, the result or effect on the patient is different. THE NURSING CARE IN MEDICAL DISEASES 469 It is thought that heat exhaustion is due to paralysis of the vasomotor center in the medulla as a result of the extreme heat. The symptoms are those of collapse—a subnormal tempera- ture usually, a pale, cool, moist skin, a weak, rapid pulse, marked weakness or extreme prostration. As a rule, the patient does not lose consciousness although syncope may occur. There may be restlessness and, in severe cases, delirium. The treatment is directed toward raising the body tempera- ture and in treating for collapse. The patient should be placed in the recumbent position with the head low; the clothing should be loosened, fresh air freely admitted, and external heat applied in the form of hot blankets, hot-water bottles, a hot bath or pack, and a hot enema. Hot tea or coffee may be given to drink and cardiac stimulants such as aromatic spirits of ammonia, caffein or strychnin. The body temperature must be watched closely in order to avoid an elevation above normal as a re- sult of the hot applications. Rest and quiet are essential until the patient is fully recovered. Meningitis and other serious after-effects are not so apt to occur as after a sunstroke, but it may be a long time (weeks or months) before the patient completely recovers. He should be watched closely and every effort made to build up the general health. Tonics are frequently required. Convulsions.—Convulsions are violent, involuntary muscular contractions. The contractions may be continued or intermittent and may be local or general. Convulsions may be classified according to (1) the character of the contractions; (2) as to whether they are local or general; and (3) the cause of the convulsion and origin of the irritation; that is, whether the convulsion is due to irritation or irritability of the motor centers of the brain or of the spinal cord. Character of the Contractions.—Contractions which are in- termittent, the muscles alternately contracting and relaxing, are called clonic. The movements are abrupt and jerky. Contractions which are long continued are called tonic. Both tonic and clonic contractions may occur in the same convulsion and frequently follow each other. Coordinate contractions are clonic contractions in which the movements seem purposeful. They are an exaggeration of the natural contractions. Local convulsions may be confined to one or a group of mus- cles. They are usually called spasms. Spasms may involve the muscles of the face, arm, leg, hand (as in writer's cramp), neck (as in wry-neck or torticollis), larynx, esophagus or diaphragm (hiccough). Cause and Origin of the Irritation.—Convulsions which result from excessive irritation or irritability of the motor centers of the brain are characterized by loss of consciousness. They are called epileptiform convulsions and are commonly spoken of as 470 THE PRINCIPLES AND PRACTICE OF NURSING fits. The contractions are chiefly clonic but may be preceded by a short tonic contraction. The convulsions arc general. Epileptiform convulsions may be caused by: (1) Idiopathic epilepsy; (2) injuries to the head with concussion, laceration of the brain, or pressure on the brain from hemorrhage or a fractured skull; (3) organic brain diseases due to meningitis, syphilis, tumors, abscesses or apoplexy; (4) toxic substances in the blood as in the acute infections, alcoholism, uremia and in poisoning by certain drugs; (5) reflex irritation as in the con- vulsions in young children resulting from gastric disturbances, intestinal parasites, teething, an adherent prepuce, the onset of an acute disease, or any condition accompanied by a rise in temperature; (6) cerebral anemia resulting from a profuse hemorrhage or from certain forms of heart disease. In convulsions resulting from irritation of the motor centers of the spinal cord there may be no loss of consciousness or only partial loss. A slight stimulus such as a noise, light, or contact with cold may cause a violent convulsion owing to the stimulated reflexes and irritability of the spine. The convulsions are called tetanic or tonic convulsions. Prolonged tonic contractions are characteristic but both clonic and tonic contractions may occur. Tetanic convulsions may result from: — (1) Tetanus or lock- jaw; (2) cerebrospinal meningitis; (3) strychnin-poisoning; (4) tetany. Hysteric convulsions are manifestations of hysteria, a disease of the nervous system. The convulsions may simulate those of epilepsy or any of the above forms so are not characteristic. They differ from those of epilepsy and other convulsions origi- nating in the centers of the brain in that while the eyes are closed and the patient may seem to be unconscious he seldom loses consciousness completely and will often respond to sugges- tion. For instance, a patient may recover on hearing a sugges- tion to pour a bucket of cold water over him. Suggestion is one of the methods used in treating hysterical patients. Other points of differentiation are that the movements are usually tonic, not clonic, the pupils react to light, there is no involuntary passage of urine, biting the tongue, frothing at the mouth, change in the pulse or in the color of the face. The patient may fall but in a place and manner in which he cannot hurt himself. In convul- sions from other causes, a patient may receive severe injuries in falling. The attacks of hysteric convulsions are usually not sudden; there may be screaming, laughing or crying during the attack and it may be more prolonged than in epilepsy and other forms. After recovery, the patient is often excited, restless, and emotional, and may laugh or cry, whereas in epilepsy the patient usually sleeps for an hour or more after the attack. Eclampsia is a sudden attack of general convulsions usually of the epileptiform type. The term is applied to the convulsions occurring in infancy as a result of reflex irritation, and to those occurring in women during pregnancy, labor, or the puerperium as a result of toxic materials retained in the blood. THE NURSING CARE IN MEDICAL DISEASES 471 The Treatment.—Coolness, presence of mind, and promptness in action are necessary in the treatment of convulsions from any cause. The patient should be placed in the recumbent position with his head slightly elevated and in a place (in bed if possible) where he cannot hurt himself. His movements may be guided so as to prevent injury to himself but should not be restrained. A gag should be placed quickly between the teeth to prevent him from biting his tongue. His clothing should be loosened and fresh air admitted freely. A patient should never be left alone while in a convulsion. The symptoms of the attack should be carefully noted and reported to the doctor on his arrival. Further treatment must depend upon the diagnosis and will be ordered by the doctor. The chief points to observe about convulsions as an aid to diagnosis are as follows:— 1. The time of the attack. 2. The onset of the attack, whether sudden, or preceded by a warning, or by nervous or emotional disturbances. 3. The character of the contractions, whether tonic, or clonic, whether one form follows the other, or whether the movements are coordinate or not. 4. The area involved, whether local or general, and if local the part affected. 5. The muscles first affected and the order in which other muscles are involved. 6. The frequency and duration of the convulsion. 7. Whether the patient is hypersensitive, conscious, semi- conscious, or totally unconscious. 8. Relaxation of the sphincters with involuntary movements of urine or stools. 9. The appearance of the eyes, whether closed or open, fixed, squinting, the pupils dilated, contracted or irregular. 10. The appearance of frothing at the mouth. 11. Any change in the pulse, respiration, or the color, or ex- pression of the face. 12. The condition of the patient following the convulsion. Convulsions in children have the same significance as a chill in an adult. They may mark the onset of an acute infectious disease such as scarlet fever or pneumonia, or may be a symptom of cerebral diseases such as meningitis, hydrocephalus, a brain tumor or abscess; or may be due to some minor cause such as teething, or constipation, or to violent emotion in a nervous, ex- citable child. Owing to their unstable nervous system minor causes of irritation may cause a convulsion in children. The Treatment.—A doctor should be summoned immediately. During the convulsion the child should be placed in a hot bath (98° to 105° F. for 1 to 2 minutes) or a mustard bath or pack in order to relax the muscles. Cold applications should be applied to the head. When the attack is due to gastro-intestinal dis- turbances a lavage may be given and a hot enema followed by a purgative—castor oil is commonly used. The child should be 472 THE PRINCIPLES AND PRACTICE OF NURSING watched closely following the convulsions and preparations made ready for repeating the treatments, as the attacks are apt to recur. The symptoms and treatment of poisoning from the use of va- rious drugs may be found in the text-book on materia medica supplied to student nurses. Apoplexy is a typical example of a spontaneous intracerebral hemorrhage from the rupture of a diseased artery due to arterio- sclerosis or miliary (very minute) aneurysms. The hemorrhage usually occurs from a branch of the middle cerebral artery which supplies the lenticular nucleus and the internal capsule. In order to understand the cause, symptoms, dangers, and treatment of apoplexy it is necessary to recall the following anatomical and physiological factors: 1. The middle meningeal artery lies over or close to the motor area of the cortex so that the hemorrhage will cause compression of these cells with resulting paralysis of muscles of the opposite side of the body. 2. The internal capsule is that part of the medulla at the base of the brain between the basal ganglia, which connects the cells in the cortex with those in the spinal cord and with muscles of the opposite side of the body. A hemorrhage here with re- sulting pressure on the nerve fibers will cause paralysis of the opposite side (hemiplegia). 3. The terminal arteries of the cortex anastomose freely but the small branches of the middle cerebral artery in the internal capsule do not anastomose and are terminal. Obstruc- tion or interference with the circulation here will, therefore, cause death of the tissue supplied by the artery injured. The accumulation of blood will cause pressure on the brain cells and nerve fibers with resulting unconsciousness and paralysis. This pressure impedes the circulation in the veins of the brain, the blood-pressure is increased to overcome this resist- ance, but if the hemorrhage is not soon checked the pressure of the accumulating blood may involve the vital centers in the medulla and become too great for the heart to overcome, and death is the result. Etiology of an Intracerebral Hemorrhage.—An apoplectic fit or stroke occurs in middle or advanced life because of the natural tendency to degeneration of the blood vessels. All the factors inducing arteriosclerosis—old age, the abuse of alcohol, overeating, syphilis, prolonged exertion and overwork, mental or physical—predispose to apoplexy. It is more common in men because of the more frequent indulgence in alcohol and because of occupations requiring muscular exertion. The exciting cause may be a sudden strain, strong emotions, worry, excitement, or a sudden "fit of bad temper" to which patients with arteriosclerosis and a high blood-pressure are subject. This is probably due to interference with the circu- lation in the brain with the resulting effect on the cells. THE NURSING CARE IN MEDICAL DISEASES 473 A nurse must constantly keep this in mind and prevent, if possible, all slight irritations or vexations for it is the seemingly trivial things which bring on the "fit of temper," and may cause the premature death of an otherwise healthy, beloved, valuable member of society. A nurse should always be very patient with old people. Some degree of arteriosclerosis is always present so that the poor supply of blood to the brain cells with resulting degeneration makes them subject to sudden spells of depression, crying, irritability, unreasonableness, impatience and temper, etc. The Symptoms.—The patient may have a few minutes' warn- ing—headache, dizziness, ringing in the ears, specks before the eyes,—but the attack usually occurs without warning. "In the typical apoplectic attack the condition is as follows: There is deep unconsciousness; the patient can not be roused. The face is injected, sometimes cyanotic, or of an ashen-gray hue. The pupils vary; usually they are dilated, sometimes un- equal, and always, in deep coma, inactive. If the hemorrhage be so located that it can irritate the nucleus of the third nerve the pupils are contracted (hemorrhages into the pons or ven- tricles). The respirations are slow, noisy, and accompanied with stertor. Sometimes the Cheyne-Stokes rhythm may be present. The chest movements on the paralyzed side may be restricted, in rare instances on the opposite side. The cheeks are often blown out during expiration, with spluttering of the lips, the pulse is usually full, slow, and of increased tension. The tem- perature may be normal, but is often found subnormal, and, as in a case reported by Bastian, may sink below 95°. In cases of basal hemorrhages the temperature, on the other hand, may be high. The urine and feces are usually passed involuntarily. Convulsions are not common." (Osier.) Apoplexy and acute alcoholism are frequently confused. The following table (Hare) differentiates them: Alcoholism. 1. Pulse rapid, compressible and weak. 2. Skin moist, or relaxed and cool. 3. Body temperature lowered. 4. Pupils equally contracted or dilated; generally di- lated. 5. No hemiplegia. 6. Breathing not so stertorous nor so one-sided in lips. 7. No facial palsy. 8. Unconsciousness may not be complete. Apoplexy. 1. Pulse apt to be strong and slow. 2. Skin hot and dry. 3. Body temperature raised. 4. Pupils unequal. 5. Hemiplegia, one side moved, the other remain- ing motionless. 6. Respiration stertorous, the lips being inflated on one side on expiration. 7. Facial palsy. 8. Unconsciousness complete. 474 THE PRINCIPLES AND PRACTICE OF NURSING "The odor of alcohol in the breath is no guide, as acute alco- holism may have caused the rupture of a cerebral blood vessel." The Treatment.— (Dr. Hare.)—The patient should be put to bed, in the recumbent position, with the head slightly elevated, the feet low. He should be kept absolutely quiet. An ice-cap or ice compresses should be applied to the head. Hot-water bottles should be applied around the body; a hot mustard foot bath may be given in some cases, to lessen the blood congestion in the head. Drastic cathartics are usually given to relieve cere- bral engorgement. When vomiting occurs, the patient must be watched closely, as the stertorous breathing may draw in the half-ejected vomitus to the lungs. No stimulants are given. Later, when bleeding is checked and there is no danger of further bleeding, potassium iodid is frequently given to cause absorption of the exudate. After all inflammation has subsided passive exercise, rubbing and massage are given to restore or prevent the wasting of the muscles of the extremities. Strych- nin is also given to stimulate the spinal cord and reflexes, and to tone up the muscles. The diet must be carefully selected. Meats are excluded or given sparingly; no wines are given as they tend to cause cerebral congestion and a second rupture. The bowels must be kept open. Venesection or bleeding has been extensively used in the treat- ment of apoplexy. Many doctors believe this% treatment to be contra-indicated, as it is now believed that the increased blood pressure present in apoplexy is Nature's way of keeping up the circulation in the brain. CHAPTER XXIX THE NURSING CARE IN THE ACUTE INFECTIOUS DISEASES The acute infectious diseases may be considered together as they have so many features in common, that general principles may be laid down which may be applied in the care of all. Typhoid, pneumonia and acute rheumatic fever, however, will be discussed separately. They come within the experience of every nurse. They require the most expert care. The principles once learned in the care of patients suffering from these diseases and the method of treating and handling them, whether it be to insure comfort, or to relieve pain, fever and toxemia or to pre- vent complications or the spread of the infection, may be applied equally well in the treatment and nursing care of all other in- fectious diseases. General Principles to be Considered.—In addition to the four principles already given in the beginning of the chapter, the treatment and nursing care in infectious diseases are governed by the following important and common factors: 1. They are all contagious or infectious. 2. They are all accompanied by fever. 3. They are all accompanied by more or less toxemia. 4. They are all apt to be accompanied or followed by com- plications. I. Nursing Care to Prevent the Spread of the Disease.— When it is suspected that a patient is suffering from an infec- tious disease the first step taken by the doctor and the first im- portant factor to be considered in the nursing care will be to isolate the patient or to put him "on precautions." The specific means taken to prevent the spread of the disease will depend upon, 1. Its degree of contagion or communicability. 2. The avenue by which the germs enter the body, the parts of the body affected, the avenue by which they are discharged and the means by which they may be transmitted. 3. The seriousness of the disease, its duration and the com- plications which may accompany or follow it. Diseases in which Patients are Placed "on Precautions."— Certain diseases which are not highly communicable and in which it is felt that the spread of the infection may be more easily controlled are, as a rule, admitted to the general wards of the hospital and the patient is put on special or strict precau- 475 476 THE PRINCIPLES AND PRACTICE OF NURSING tions. This means that the nurse attending him will wear a cap and gown and in some cases gloves. All the dishes, utensils and other articles used by and for the patient will be carefully marked with his name and isolated from other articles. The precautions in the disposal of secretions and discharges and the disinfection of all articles both during and after the disease are the same as outlined under the nursing care during isolation. The nurse must be particularly careful to prevent the spread of the disease when obliged to care for other patients. The infectious diseases which may be found in the general wards of many hospitals are pneumonia, typhoid, tuberculosis, influenza, gonorrhea and, in some, both tuberculous and cerebro- spinal meningitis. In the latter disease the mortality is so high and the complications may be so serious that in some hospitals the patients are isolated. Diseases in which Patients are Isolated.—Such diseases as scarlet fever, diphtheria, measles, chicken pox (varicella), mumps (parotitis), whooping cough (pertussis), smallpox (variola), cer- ebrospinal meningitis and infantile paralysis (poliomyelitis) are all highly communicable so that patients suffering from these diseases are completely isolated from others. Diphtheria and meningitis are known to be spread by "carriers," that is, by people having the germ in their nose or throat which they may convey to others without themselves having the disease. All the above diseases may be spread by a third person, such as the nurse or doctor in contact with the patient. Children are particularly susceptible to the acute infections so special pre- cautions must be taken to prevent contact either direct or indi- rect between the patient and other children. The rules govern- ing the isolation of such diseases as scarlet fever, diphtheria, in- fluenza, measles, smallpox, meningitis and poliomyelitis must be most strictly observed not only because these diseases are serious in themselves but because of the serious and often fatal com- plications which are apt to develop. Rules Governing Isolation of a Patient.—Isolation means the complete separation of the patient and the prevention of either direct or indirect contact between the patient and other people, particularly children. The room or ward should be, if possible^ remote from others. Communication between the sick room and the rest of the house should be avoided as far as possible. The room should be large, well-ventilated, sunny, clean and free from dust. There should be no unnecessary articles or fur- nishings in the room. All furniture and other articles in the room should be dusted with damp dusters. A disinfectant solu- tion such as bichlorid of mercury 1:1000 or carbolic 1:40 may be used for dusting. When the disease is air-borne, as in scarlet fever and smallpox, sheets saturated with carbolic 1:20 are some- times hung across the door leading to the sick room. The room should be screened from flies. The Nurse and Physician.—No one, if possible, but the nurses NURSING IN THE ACUTE INFECTIOUS DISEASES 477 and doctor should come in contact with the patient. Each should wear a cap and gown and when examining or treating a bad throat, as in scarlet fever or diphtheria, should also wear rubber gloves. The cap and gown worn by the physician should hang outside the sick room, in the bathroom or an adjoining room used in the care of the sick. All articles or instruments used in an examination of the patient, including the stethoscope, should be left in the sick room and disinfected after use. The physician should not remain longer than necessary in the sick room. Provision should be made for the doctor to wash his face and hands and a disinfectant such as alcohol, or bichlorid of mercury 1:1000 should be provided. The nurse should guard her own health by taking proper meals, exercise, fresh air, rest and sleep and should avoid fatigue, exposure to cold, and catarrh or common colds. Before going out she should bathe and change her clothing. When out she should avoid susceptible individuals, particularly children. In taking care of a patient suffering from such diseases as scarlet fever, diphtheria, influenza, meningitis, poliomyelitis, smallpox, measles, mumps or whooping cough in which the germ is present in the secretions of the nose, mouth or throat, the nurse should avoid the spray from the patient's nose and throat when cough- ing or sneezing, etc She should spray her own nose and throat with a mild antiseptic, both to protect herself and other people, because, from close contact with, the patient, the nurse is apt to be a carrier. Strong, irritating antiseptics should not be used as irritation of the mucous lining predisposes to infection. Specific Precautions taken by the Nurse and Others Exposed.— In Diphtheria.—When diphtheria develops all those who have been in contact with the patient should have a nose and throat culture taken. They may be "carriers" or may be developing the disease. The nurse and those directly exposed should be immun- ized by receiving injections of diphtheria antitoxin. In Typhoid, Smallpox and Whooping Cough.—It is unwise for a nurse to take charge of these diseases unless she has previously had them or has been immunized against them. Successful vac- cination against smallpox and previous injections of typhoid vaccine are sufficient protection against these diseases. The value of pertussis vaccine has not yet been fully demonstrated. While an attack of whooping cough might not be serious to the nurse, the duration of the disease is prolonged so that it would completely interfere with her professional duties. Precautions in the Sick Room.—All articles used by or for the patient, such as the thermometer, wash basin, bathtub, dishes, bedpan, urinal, sputum cup or other utensils should be isolated with the patient. They should be disinfected after use and, where possible, kept in a disinfectant when not in use. Bed linen should be disinfected before sending to the laundry. Articles should be disinfected by boiling when possible. If it is necessary to re- move them to some other room for boiling, they should first be 478 THE PRINCIPLES AND PRACTICE OF NURSING placed in a receptacle containing a disinfectant solution such as carbolic acid 1:20. The receptacle should stand outside the door of the sick room. The nurse should be careful not to con- taminate the cover or handle of the receptacle. Animal pets should not be allowed in the room and only such toys as may be afterward destroyed should be permitted. Care of Secretions and Discharges from the Body.—The care taken in regard to the secretions and discharges depends upon the avenue by which the germs enter the body, the avenue by which they are discharged and the means by which they are transmitted. Secretions from the Eyes, Nose, Mouth or Throat.—As pre- viously stated, when caring for a disease in which the germ is present in the eyes, nose, mouth or throat, a nurse should avoid the spray from the nose or mouth when the patient is sneezing or coughing or even when talking or laughing. All such secre- tions should be received on cloths which should be destroyed by burning. Small squares of old muslin or gauze should be used so that they may be used only once and placed immediately in a paper bag. A patient should never be allowed to place hand- kerchiefs under the pillow or in the stand drawer, etc. Sputum boxes, when used, should be cleansed and disinfected daily. Dried secretions must not be allowed to remain in them or on the outside. The nurse should use extreme care when handling such secretions. Rubber gloves may be worn. All the secretions and discharges from the body (urine, stools and skin discharges) should be burned or disinfected in such diseases as typhoid, poliomyelitis and smallpox. The urine and stools should also be disinfected in dysentery and tuberculosis of the kidneys or intestines. Separate bathtubs, bedpans and urinals should be kept and disinfected after use. Separate bed- pans and urinals should also be used in gonorrhea and the vagi- nitis of children. Before the patient is discharged, he should be given a thorough soap and water bath followed by a bath of bichlorid of mer- cury 1:5000. His hair should be shampooed and his eyes, ears, nose and mouth should be carefully cleansed. An antiseptic spray should be used when the nose or throat has been infected as in scarlet fever, diphtheria, influenza, meningitis and polio- myelitis, etc. Disinfection and Fumigation.—All articles, such as books and toys, should be destroyed. All bed linen, dishes and utensils, etc., should be sterilized. Blankets, pillows and mattresses should be sterilized by hot air or steam under pressure. If this is not pos- sible, they should remain in the room during the fumigation. They should then be whisked with an antiseptic solution and where possible, put in the open air and direct sunlight for sev- eral successive days. The room after fumigation should receive a thorough cleansing. II. Fever or Pyrexia.—It is now thought that the elevated NURSING IN THE ACUTE INFECTIOUS DISEASES 479 temperature is a protective, defensive reaction on the part of the body which enables it to combat the bacteria and their toxins. The fever is due to increased oxidation with heat pro- duction and diminished heat elimination. It is thought to be chiefly due to the fact that the heat-regulating centers for the time being, set the body temperature at a higher level than nor- mal, that is, they so regulate heat production and elimination as to maintain the body temperature at a point which best enables it to defend itself. If it is very high (hyperpyrexia) or pro- longed, however, fever is not only harmful to the bacteria, but to the body cells and must therefore be reduced by appropriate treatment. It causes increased oxidation and actual destruction of body protein, not only interfering with the function of the cells but actually destroying them. Excessive or prolonged fever will cause marked emaciation, lowered resistance and prostration. III. Toxemia.—Toxemia is present in a more or less marked degree in all infectious diseases. Toxins cause marked destruc- tion of body proteins. They attack the vital centers in the brain, the vital organs, the muscles of the heart and other muscles throughout the body and the secreting glands. The secretion of saliva, gastric and intestinal juices, the urine, perspiration and other secretions are interfered with. The muscles of the heart may be poisoned so that the pulse becomes weak and rapid; the muscles of the arteries may lose their tone so that the blood- pressure is lowered and the heart further depressed; the muscles of the intestines may lose their tone resulting in distention; the muscles of the bladder may lose their tone, resulting in retention of urine. Loss of tone in the skeletal muscles results in great weakness. Tissue destruction causes marked emaciation so that the patient may become completely prostrated. The fever is usually an indication of the toxemia, but not always. A patient may have a high fever with little toxemia, or a relatively low temperature with a marked toxemia. The clinical picture varies with the degree of fever and toxemia and the kind of toxins elaborated by the different bacteria so that in certain diseases the clinical picture is characteristic and diagnostic. For instance, the toxic pneumonia patient is wake- ful, alert, keenly interested and anxious about his condition, although he may desire only to be let alone. He knows his con- dition is serious and watches your expression, trying to pierce your professional expression and manner in order to learn what the outlook may be. He may become wildly excitable and vio- lently delirious. The toxic typhoid patient is wakeful, lies with his eyes open but seeing nothing and is disinterested in what goes on around him. He is usually dull and stupid. He feels comfortable, has no desires and no complaints. He may become violently delirious but as a rule is quiet, in a state of stupor with constant low mutterings and tremor and restless movements of the fingers, but seldom tries to get out of bed as the toxic pneu- monia patient does. 480 THE PRINCIPLES AND PRACTICE OF NURSING In cerebrospinal meningitis, the early stage of the disease is characterized by a period of excitement, with headache, rest- lessness, irritability, hyperesthesia (the patient jumps and starts at the slightest sound), and delirium. This is followed by a pe- riod of depression, in which the patient is completely prostrated and in a state of coma. In diphtheria, the fever and toxemia usually coincide with the extent and severity of the throat lesion but the prostration is sometimes out of all proportion to the severity of the local proc- ess in the throat and other febrile symptoms. In scarlet fever, the temperature is usually high, nervous symptoms and pros- tration may be marked. In smallpox, the temperature is usually high and delirium may be marked. Such diseases as mumps, whooping cough and chicken pox are not usually accompanied by a high fever or toxemia. The symptoms to be relieved, which usually accompany fever and toxemia, are chilly sensations, headache, pains in the back, aching limbs, thirst, coated tongue, dry mouth and lips, a dry, hot skin, loss of appetite, nausea, vomiting, diarrhea or constipa- tion, a rapid pulse, malaise and weakness. The nervous symp- toms may be restlessness, excitement, irritability, insomnia, men- tal confusion, delirium, convulsions or apathy and stupor. IV. Complications apt to Accompany or Follow Infectious Diseases.—The complications and sequelae to be feared and the measures taken to prevent them depend upon the disease. In scarlet fever, they are nephritis, otitis media, adenitis and pneumonia. In diphtheria, they are bronchopneumonia, myocarditis, neph- ritis, asphyxia, paralysis of the soft palate, muscles of the pha- rynx or respiratory muscles and cardiac paralysis with heart failure which may occur when convalescence is almost complete. In measles, the lowered resistance of the mucous membrane of the respiratory tract predisposes to infection by streptococci, staphylococci, pneumococci, tubercle bacillus and others. Bron- chopneumonia, bronchitis, diphtheria, otitis media, adenitis, ulcerative stomatitis, conjunctivitis and tuberculosis may follow. The patient is rendered particularly susceptible to tuberculosis. In whooping cough, bronchopneumonia, hemorrhages and con- vulsions are the most serious complications to be feared. In mumps, orchitis may be a serious complication in boys after puberty. In influenza, complications are very common and serious. The most common are otitis media, mastoiditis, pneumonia, tonsilli- tis, bronchitis, pleurisy, rhinitis and inflammation of the sinuses. Meningitis, neuritis, marked mental depression, melancholia and other psychoses may also follow. In poliomyelitis, paralysis of the muscles of the extremities, trunk or diaphragm is to be feared. In meningitis the complications and sequelae to be feared are otitis media, deafness, blindness, paralysis, mental deterioration, epilepsy, arthritis, septic pneumonia, endocarditis and pyelitis. NURSING IN THE ACUTE INFECTIOUS DISEASES 481 The Nursing Care and Treatments to Relieve Fever and Toxemia and Prevent Complications.—The underlying princi- ples in the treatment of all diseases accompanied by fever are the same. The treatment includes (1) rest. (2) diet. (3) fresh air and general hygienic care. (4) local applications and hydrotherapy. (5) drugs, sera, vaccines. Rest.—The destruction of body tissues, the crippled heart and blood vessels and the muscular weakness due to the fever and toxemia make rest of mind and body absolutely essential. The body tissues are putting up a tremendous fight against the in- fection and all its energy must be conserved for that purpose. Rest means rest in bed and freedom from all causes of discom- fort and unnecessary exertion. It also means freedom from worry, excitement, irritability, insomnia or delirium, all of which cause restlessness and the loss of energy by strained and restless muscular movements. Visitors, conversation and anything in- volving mental effort should be excluded. Every extra breath or heart-beat, every unnecessary movement or strained, uncom- fortable position means additional and inexcusable waste of valuable energy. The degree of rest required varies in the dif- ferent diseases and with the severity of the attack. In those diseases in which fever and toxemia are marked or in which heart complications or nephritis are feared the need for rest is particularly great. For instance, in diphtheria absolute rest and quiet are essential on account of the extreme danger of heart- failure and nephritis. Every unnecessary demand on the heart increases the danger and all forms of muscular movements mean increased destruction of body tissues and increased protein ashes to be eliminated by the kidneys. The danger of heart- failure in diphtheria increases as convalescence approaches. The patient must lie flat on his back, with one pillow only, through- out the disease and convalescence. On no account should he be allowed to sit up. All causes of excitement and movements apt to increase the strain on the heart must be avoided. In diph- theria and in all severe toxic cases or when the heart is weak- ened, the patient should never be allowed to turn or feed him- self or even to lift his head. A nurse should always find out from the doctor the amount of exertion or exercise the patient may be allowed. The degree of rest should be prescribed just as are the diet and drugs. Diet.—Fever and toxemia have a very important bearing on the diet. The energy required to combat the disease infection, the necessity for maintaining an increased body temperature and the prevention of tissue destruction make the diet a very influential factor. In ordering the diet the physician is guided by the following principles. (1) The necessary energy and ma- terial to repair body tissues must be derived from the food. Otherwise the body will be forced to use its own tissues and this will result in emaciation, loss of strength and lowered resistance, which predisposes to secondary infections and other complica- 482 THE PRINCIPLES AND PRACTICE OF NURSING tions or to a prolonged convalescence. The destruction of body tissues also leads to the formation of toxic products which adds to the general toxemia. (2) It has been estimated that the average healthy man at rest requires 2300 calories to meet the daily needs, whereas a patient at rest, but with a high fever, re- quires 2800 to 3000 calories to meet the daily needs, prevent loss of body tissues and enable the body to combat the disease. This must be derived from protein, carbohydrates and fats. (3) The amount of protein allowed is barely sufficient to meet the body needs, that is, about 75 to 85 grams. Protein leaves a large amount of ashes to be eliminated and so increases the work of the liver and kidneys, which are already poisoned and over- worked by the toxins. This increases the clanger of nephritis. Proteins are not required to produce heat or the power to do work so that, as there is no provision for storage, only an amount sufficient to repair the wear and tear in the tissues is allowed. (4) Carbohydrates are not only the most easily digested foods and form the most efficient fuel to produce heat but they are great "protein sparers," preventing the wear and tear and de- struction of body tissues. (5) Carbohydrates and fats are either stored in the body or are completely burned, leaving little waste (carbon dioxid and water) to be eliminated so do not add to the burden of the kidneys. (6) The loss of appetite, the poor digestion and digestive disturbances usually make it impossible to give the full caloric needs during the early stages of an acute fever. No effort is made, as a rule, to force the diet, particu- larly when the acute stage is of short duration. When the dis- ease is prolonged, as in typhoid, or when complications prolong the disease efforts are made to increase the diet to meet the body needs in order to prevent emaciation and lowered resist- ance. In all cases, as soon as the appetite and digestion permit, the diet is gradually increased. Fluid diet only is usually given in the acute stage. Water should be given freely and at regular intervals whether the patient seems to want it or not. Orange- age, lemonade and imperial drink should be given in addition to water. They are grateful and refreshing and are a means of supplying water and sugar. Water helps to keep the mouth in good condition, relieves thirst, dilutes toxins, aids in their elimi- nation, lessens the toxemia and the danger of nephritis. The diet is therefore much the same in all fevers, with modi- fications to fit the individual case. In diseases, such as scarlet fever, in which nephritis is apt to develop, special care is taken by limiting the protein so as not to overtax the kidneys. Milk is the basic diet (see nephritis) and the patient is encouraged to take water, orangeade, lemon- ade and imperial drink. In diphtheria, while the fever is usually not high, the destruction of tissues by toxins may be marked so that it is most essential to repair the loss by a nourishing diet. When pain, difficulty in swallowing or regurgitation of the food through the nose occur (due to the effect of the toxins on the NURSING IN THE ACUTE INFECTIOUS DISEASES 483 nerves and paralysis of the soft palate and pharyngeal muscles) the food must be given by nasal gavage, by rectum or through a stomach tube. In whooping cough, feeding is sometimes a diffi- cult problem owing to digestive disturbances and the fact that taking food may cause a paroxysm of coughing followed by vomiting. Food should never be given at a time when the paroxysm of coughing is likely to occur but should be given after the paroxysm as it is usually followed by a period in which breathing is more quiet and the stomach is at rest. No dry foods should be given or food likely to irritate or cause difficulty in swallowing. Small amounts only should be given and the patient should eat slowly. All forms of excitement should be avoided. Children with whooping cough are apt to be irritable because the nerves are particularly affected and trivial things may cause a severe paroxysm of coughing. Coughing and vomiting are in themselves exhausting. In a prolonged illness like whooping cough, the loss of food and lack of nourishment are a serious drain on the patient's strength. In mumps, acid food and drinks some- times cause pain. When such is the case they should be avoided. General Hygienic Care.—Plenty of fresh air is highly desir- able in the treatment of all infectious diseases. Fresh air is par- ticularly valuable in diseases such as measles, whooping cough and diphtheria, in which bronchopneumonia may be a serious and often fatal complication. At the same time the patient must be properly protected from drafts, exposure and chilling. In whooping cough, drafts, a slight chill, being placed in a cold bed, or getting uncovered, may bring on a severe paroxysm of coughing. Flannel should be worn next the body on account of the sweating, which often occurs with coughing. Special care should be taken in scarlet fever to avoid chilling on account of the extreme danger of nephritis. The patient should be kept in bed not only during the disease but also in convalescence as the danger of nephritis is increased toward convalescence. Care should be taken in the use of the bed pan and in all other treat- ments, to avoid exposure and chilling. A flannel nightgown is advisable. In meningitis, also, the patient is very sensitive to cold so should wear a flannel gown (unless flannel is irritating) and should have sufficient clothing to keep him warm. Light, with direct sunlight if possible, is also highly desirable, but should be so regulated as to cause no discomfort to the patient. In meningitis, however, on account of the hyperes- thesia and sensitiveness to noise and light, the room should be both quiet and dark. No visitors or excitement, no creaking of doors or windows, no jars or noise of any kind should be allowed. In measles, the patient's eyes are frequently very sensitive to light, which must be regulated to avoid annoyance or discomfort. Care of the Skin.—Daily cleansing baths are essential for comfort and cleanliness and to stimulate the circulation and functions of the skin. Exposure and chilling must be avoided in all cases but particularly in scarlet fever and diphtheria, on 484 THE PRINCIPLES AND PRACTICE OF NURSING account of the danger of nephritis and in meningitis on account of the sensitiveness to cold. In diseases accompanied by a skin eruption special care of the skin is necessary. In scarlet fever and measles, bran baths or baths containing bicarbonate of soda are frequently used to relieve itching and burning. Oiling the skin or soaking it in warm water softens and aids desquamation in scarlet fever. Picking and pulling at the skin should not be allowed as it is apt to injure the tissues. In a severe case of chicken-pox, at the height of the eruption, the regular cleansing bath cannot be given on account of the danger of breaking and infecting the vesicles or injuring the tissues, with resulting per- manent scarring. Severe itching is relieved by gently applying a solution of bicarbonate of soda 1 dram to a pint. The erup- tion should be kept as dry as possible by the use of sterile dust- ing powders. In smallpox, the care of the skin is one of the most important and difficult problems. At the height of the eruption, regular cleansing baths cannot be given. Sometimes the patient is immersed in a warm (95° F.) continuous bath of plain water or water containing bicarbonate of soda. Itching and burning may be relieved by cold compresses or hot compresses may give greater relief. Various applications are used to relieve itching and discomfort and to soften the pustules. These may be in the form of ointments or oily substances such as vaselin or sweet oil to which 3 per cent, to 5 per cent, carbolic is sometimes added. Carbolic relieves the itching. In all diseases accom- panied by skin eruptions, scratching must be avoided. With children it is necessary to cover the hands or to apply splints so that they cannot bend the elbows or to secure the hands in such a way that they cannot scratch the face. The Prevention of Bedsores.—The danger of bedsores is par- ticularly great and special care is required when the fever, tox- emia and emaciation are marked or when the nerves are involved as in meningitis and poliomyelitis or when the disease is pro- longed. Care of the Mouth, Nose, Throat, Eyes and Ears.—Special care of the eyes, nose and mouth is essential in all fevers not only for the patient's comfort but to lessen the toxemia and to avoid serious complications. In those diseases in which the se- cretions are increased and contain the organism extreme care is required also to prevent the spread of the disease. Pyogenic or- ganisms are always prevalent in uncared for mouths and may cause ulcerative stomatitis, otitis media, adenitis, bronchitis and bronchopneumonia. In diphtheria, lack of care and the presence of a mixed infection greatly increase the toxemia and danger of bronchopneumonia, a complication frequently fatal. In menin- gitis, the presence of herpes and sordes and in smallpox the pres- ence of the eruption in the eyes, nose and mouth demand extra care. An ointment, oil or vaselin may be applied to the lids to prevent them from sticking together or to prevent the forma- tion of dried secretions. In all cases the mouth should be NURSING IN THE ACUTE INFECTIOUS DISEASES 485 cleansed frequently. Mild antiseptic sprays are used to cleanse the nose. Cold cream or vaselin may be used to soften dried secretions. If nasal irrigations are ordered they should be given with extreme care to avoid causing otitis media. Sprays and irrigations are used for the throat. In measles, the eyes should be cleansed several times daily. In diphtheria and infantile paralysis, paralysis of the soft palate and muscles of the pharynx may occur and interfere with swallowing. If the mouth and throat are not properly cared for, infected secretions and par- ticles of food may be carried into the lungs and cause septic or foreign body pneumonia. In all cases care must be taken in cleaning the nose, mouth or throat to avoid irritation or injury to the mucous membrane as this aggravates the condition and increases the danger of mixed infections. In diseases of the upper respiratory tract, in all of which otitis media is a complication to be feared, the ears should be exam- ined daily. Symptoms of pain, tenderness, irritability, a rise in temperature or a discharge should be noted and reported immediately. Elimination by the Bowels and Kidneys.—In all infectious diseases, but particularly when the toxemia is marked, and when nephritis is feared as a complication, the elimination by the bowels and kidneys should be closely watched. The bowels should be kept open by the use of cathartics or enemata, if nec- essary. Retention of urine should be watched for and treated if present. To avoid nephritis, the urine should be examined for albumin daily, both during the disease and convalescence. Relief of Annoying Symptoms and Discomforts.—Fever, when necessary, is relieved by cold sponge baths, packs or baths and by the use of the coal tar products, acetanilid, antipyrin and phenacetin. Headache is relieved by the reduction of fever, by the relief of toxemia, by cold baths or packs and by the application of an ice-bag or ice compresses. Racking pains in the back and aching limbs are also relieved by acetanilid, antipyrin and phenacetin. The extreme hyper- esthesia, pain and sensitiveness of muscles and limbs to pres- sure or handling which occurs in meningitis and poliomyelitis, demand extreme care in moving, turning or lifting the patient. Special attention must be given to the sensitive spine. The stiff muscles of the neck and back, with the head thrown back and the back curved, indicate that the body is trying to keep the part absolutely at rest, and the spine protected so as to avoid irrita- tion and .pain. Particular care should be taken when lifting the head and in the arrangement of pillows. The body and sensi- tive parts should be put completely at rest and all forms of irri- tation, pressure or discomfort removed. A cradle may be used to keep the weight of bedclothes from a sensitive limb or a splint may be applied to keep it at rest. As in all conditions where it is necessary to lift the bedclothes 486 THE PRINCIPLES AND PRACTICE OF NURSING from the body by the use of a cradle, means should be taken to keep the parts from becoming chilled. The extreme hyperes- thesia, pain, and sensitiveness to cold in meningitis and poliomye- litis make extra care necessary. An electric light may be sus- pended from the cradle. Heat is one of the best means of re- lieving pain. Local applications of dry or moist heat may be used for sensitive parts. The position should be changed from time to time. Irritability, restlessness, insomnia, and delirium are relieved by cold baths or warm sedative baths, by the application of an ice coil to the head and by sedative drugs such as bromides or codein. For wild delirium morphin may be necessary to relieve restlessness and sleeplessness. Coughing is relieved by steam inhalations, by the application of counter-irritants to the chest and by the use of sedative drugs such as codein and heroin. Digestive disturbances such as loss of appetite, nausea and vomiting are treated chiefly by a careful regulation of the diet. Thirst is relieved by careful attention to the mouth and by giving plenty of water, orangeade or lemonade, etc., to drink. The sore throat in scarlet fever and diphtheria is relieved by hot or cold applications to the neck and by the use of steam inhalations, sprays and throat irrigations. When dyspnea is very severe an intubation or tracheotomy will be necessary to prevent asphyxiation. For symptoms of heart failure, heart stimulants such as caf- fein, camphor, adrenalin, and digitalis are used. Cold fresh air treatment is also valuable. Specific Treatment.—In diphtheria, diphtheria antitoxin is used as an antidote, that is, to give a passive immunity to diphtheria. The immunizing effect of diphtheria antitoxin takes place in a few hours and continues for an average period of about two weeks. It is of value, therefore, when an immediate protection is demanded as when a susceptible individual or one whose sus- ceptibility has not been tested, is exposed to diphtheria. In the treatment of diphtheria, large doses, given early, will in most cases effect a cure. The antitoxin checks the spread of the mem- brane, softens and loosens it, reduces the swelling and improves the general condition. The breathing and pulse are improved, the temperature is lowered and other toxic symptoms subside! Disagreeable results sometimes follow several days after the in- jection of antitoxin. These consist in a rash which may be accompanied by pains in the joints, an elevated temperature and swollen glands. They disappear in two or three days usually. The amount of antitoxin and the method of giving vary with the age and weight of the individual and with the severity of the attack. In infants, the dose varies from 2000 units in mild cases to 10,000 units in malignant cases. In adults, the dose varies from 3000 units in mild cases to 40,000 units in malignant cases. NURSING IN THE ACUTE INFECTIOUS DISEASES 487 The antitoxin should be warmed to body temperature and given very gradually into an area where there is an abundance of subcutaneous cellular tissue such as the abdomen or infra- scapular region. The skin should be sterilized, the syringe and needle should be sterile. Injections should be made as follows:— In mild cases —subcutaneous or intramuscular In moderate cases—intramuscular or subcutaneous In severe cases —intramuscular, subcutaneous, intravenous In malignant cases—intravenous or intramuscular. When given intravenously one-half the usual dosage is given. It is better not to employ massage over the point of injection.1 In cerebrospinal meningitis, lumbar punctures are performed as an aid to diagnosis, to relieve pressure due to increased fluid and exudate, and for the purpose of injecting antimeningitis serum. The antimeningitis serum is a specific immune serum of thera- peutic value only in meningococcic meningitis. If given early, it is capable of reducing the mortality rate 60 per cent, and of lessening the tendency to serious after-effects such as blindness, deafness, paralysis and deformities, in those that recover. It checks the inflammatory process, stimulates phagocytosis, checks the growth of the meningococcus and causes the turbid cerebrospinal fluid to become clear. Administration.—Following a lumbar puncture, by which the canal is drained (that is, the fluid is allowed to flow very grad- ually until the pressure is so reduced that only 3-4 drops corne per minute), an amount of antimeningitis serum, a little less than the amount of fluid withdrawn, is injected subdurally. The serum is first warmed to body temperature and then injected very slowly under the least possible pressure. If these precau- tions are observed abnormal changes in the blood-pressure may be avoided.1 Watch the patient for the slightest change in pulse and respi- ration. Injecting too much serum or injecting it too quickly may cause the respirations to cease and the pulse to become very weak, rapid and thready during or immediately after the treat- ment. If the needle is still inserted, withdrawal of fluid may re- lieve the symptoms—if not, artificial respirations, adrenalin or other heart stimulants should be given. The amount of cerebrospinal fluid (in an adult) usually with- drawn is about 25 c.c and the amount of serum injected is usually a little less, about 20 c.c. The number of injections varies with the severity of the disease and is continued—every 12 hours or every day—until the fluid is sterile. Usually 4-6 injections are necessary but as many as 15 or more may be required. Convalescence from Infectious Diseases.—During convales- 1 Health Department, New York City. 488 THE PRINCIPLES AND PRACTICE OF NURSING cence, especially if the disease is prolonged, the patient requires careful nursing. Fresh air, sunlight, nourishing diet, the proper amount of exercise and freedom from worry, etc., are essential to enable the patient to regain his normal strength. Tonics are frequently prescribed. In some diseases the danger of compli- cations continues throughout convalescence. These demand extra care. For instance, in scarlet fever, nephritis is more apt to develop toward or during convalescence. The urine should be examined daily for albumin, and all precautions used to pre- vent nephritis during the height of the disease should be con- tinued. Convalescence in diphtheria is a very critical period because complications, which may prove fatal, may develop. Paralysis may occur, particularly of the soft palate, pharyn- geal or laryngeal muscles. This may occur at the end of the second week and makes feeding very difficult and demands great care. Paralysis of the soft palate causes food to regurgitate; of the pharyngeal muscles, causes choking and difficulty in swallowing; of the pharynx and larynx, causes secretions to ac- cumulate, prevents their expulsion, and may allow food to enter the lungs and set up a foreign body pneumonia. If the mouth and throat are not clean the food will be infected and may cause septic pneumonia and abscesses. Careful cleansing, keeping the head turned to one side, slight elevation of the foot of the bed and aspiration of the throat will help to prevent this. Feeding by the stomach tube, by nasal gavage or by rectum may be necessary. The respiratory muscles may be paralyzed so that care must be taken to avoid conditions which in any way inter- fere with breathing, such as the condition of the nose and throat, the patient's position, weight of the bedclothes, or applications to the chest, gastrointestinal disturbances, or the ventilation, etc. These paralyses are temporary. Cardiac paralyses and heart failure may occur in diphtheria during convalescence. Any sudden change in the pulse rate, either an increase or a decrease, is a very grave symptom. The heart failure may be due to the effect of the toxins or to paralysis of the pneumogastric nerve. This is especially apt to happen in those who have been very toxic and where paralysis of other nerves has occurred. Other symptoms of this alarming condi- tion are pain, dyspnea, restlessness and vomiting. During convalescence, therefore, especially in those who have been toxic, the slightest exertion or excitement, etc., must be avoided as even a slight exertion may prove fatal. Even in mild cases heart failure may occur. Nephritis may also occur. The urine should be examined daily. All predisposing causes should be avoided. TYPHOID OR ENTERIC FEVER Typhoid fever is an acute, general, specific, infectious, com- municable disease with local lesions in the intestines. NURSING IN THE ACUTE INFECTIOUS DISEASES 489 Nursing Care and Treatment.—Dr. Osier has said that "care-1 ful nursing and a regulated diet are the essentials in a majority of cases," and that the disease can only be modified by placing the patient in the best possible mental and physical condition to withstand the invasion of the bacteria and their toxins. It is a disease in which attention to the little details is most important and brings the best results. "That sufficient physical and mental rest and sleep are ob- tained, if possible," is the first important factor. "Real rest can be obtained only by careful and competent nursing." There are several factors which make rest in typhoid fever essential. The battle is a prolonged siege, lasting from four to six weeks or longer; the temperature is continuously high and the toxins extremely poisonous, depressing the vital centers and causing marked destruction of tissues; insomnia is frequently present, the patient lying awake night and day (coma vigil). Typhoid is therefore very exhausting and leaves the patient an easy victim without resistance or strength to withstand a sec- ondary infection or other complication. Every ounce of strength must be saved and he must be protected as far as possible from other forms of infection. Rest means not only rest in bed, but in a comfortable bed, free from all sources of discomfort. The position must be com- fortable, never strained, to avoid pain or other discomfort. The patient should never be allowed to sit up. The position should be changed frequently, but the patient should not be allowed to move himself. All exertion must be avoided in making the bed, giving a bath or other treatments, using the bedpan, and in feeding him, etc. Every movement is a waste of energy so everything should be done for him. Mental rest—freedom from cares, anxiety, excitement and all mental demands, all of which cause fatigue—is essential. Nervousness and excitement during treatments, or due to forced diet, etc., must be avoided. No visitors should be allowed; the mental effort of listening to or keeping up a conversation causes an elevated temperature, a rapid pulse, restlessness, and wakefulness. Cold baths usually relieve nervousness, excitement and wakefulness; sometimes chloral, bromids or opium is necessary. The Relief of Annoying Symptoms and Discomforts which sap the patient's vitality and often obscure the true state of the system is the next important factor. The Ward or Room.—There should be plenty of air space with an abundance of fresh air. Cold air is best, as it has the same stimulating effect on the vital centers, the heart, lungs and metab- olism, as cold baths. Care must be taken to avoid drafts, particularly when the body temperature is low. At the height of the fever drafts are not dangerous. The room should be as quiet as possible. In fever, especially in typhoid fever, noises of all kinds are very distressing. Avoid noise, excite- ment, disorder, commotion, visitors and unnecessary conversa- 490 THE PRINCIPLES AND PRACTICE OF NURSING tion; if necessary to speak, speak in a natural tone of voice. The amount of light is important; note whether irritating or not, and arrange to suit the patient. Light sometimes causes head- ache, nervousness and sleeplessness. In the toxic state the eyes are frequently kept wide open so are apt to become irritated. At night it is well to have a shaded light and the patient should be under close observation night and day; he is often quiet dur- ing the day and delirious at night. Patients sometimes desire a light at night. A room in a private home should have, as far as possible, all the characteristics of the hospital ward—large, well ventilated, proper lighting, free from unnecessary furnish- ings, quiet, systematic, orderly, no visitors and with proper facilities for the disposal of discharges, etc., and the care of linen. The bed must be clean, comfortable, dry, free from wrinkles, crumbs or any other source of discomfort or cause of bedsores. It must be well protected as the patient is apt to have invol- untary movements. It must not be too warm and the clothes, particularly over the toes, must not be too tight—typhoid pa- tients have poor circulation, and sometimes suffer from local neuritis with extremely tender toes. The Patient.—He should have a daily cleansing bath and everything about him should be kept sweet and clean. His hands should be washed several times a day. A delirious.patient is apt to contaminate his hands with fecal material and reinfect himself. The position must be the constant recumbent, but should be changed frequently to avoid pneumonia and pres- sure sores. Bedsores.—The marked emaciation, the destructive effect of the fever and toxins, the impaired metabolism, poor circulation, low blood-pressure (shown by the patient's dusky hue), the prolonged illness, and the profound involvement of nerve centers make even slight pressure a source of great danger. The patient may lose control over the bladder and rectum and this adds to the danger. The proper care of the skin, the cold sponge and cold tub-baths by stimulating the circulation and the functions of the skin aid greatly in preventing bedsores. The care of the mouth and nose is extremely important. If neglected the mouth becomes dry, the tongue coated with a white, brown or brownish black fur and crusts form with cracks and fissures between which are extremely painful. Ulcerations may occur. The dryness is due to the fever, lack of fluid in the tissues, diminished saliva and to breathing through the mouth. It makes swallowing difficult and results in cracks and fissures. A neglected mouth may cause infection of the ears, tonsils, lungs, parotid glands, erysipelas, and the patient may reinfect himself with typhoid. It makes the patient uncomfortable, has a de- pressing mental effect, destroys the appetite, upsets the stomach and digestion. Parotitis may develop in the third week and is extremely serious. The mouth must be kept clean and moist. It should be cleansed morning and evening and after each feeding. Care NURSING IN THE ACUTE INFECTIOUS DISEASES 491 must be taken not to cause the patient to gag, also to avoid in- jury to the delicate mucous membrane. Cold cream should be applied to the lips and tongue half an hour before cleansing to soften a tender or badly coated tongue. Plenty of water to drink aids greatly in keeping the mouth in good condition. Bits of cracked ice to suck relieve the dryness and thirst. Inflammation and increased secretions in the nose are common. The secretions become dried, forming crusts and scabs, and cause the patient great annoyance. The nose must be kept clean and the patient must not be allowed to pick at it. Cold cream should be used to soften and relieve irritation. Note any bleeding from the nose. Headache is a common and most distressing symptom. It should be relieved by the application of an ice-cap or ice com- presses to the head. Backache and Aching Limbs.—The spine is frequently very tender and pains in the back and limbs may cause great suffer- ing. Pillows should be arranged so as to support the back and keep the tender spine entirely free from the bed. Sleeplessness is a most exhausting symptom. It is relieved by hydrotherapy, chloral, bromids, or morphin, etc. Thirst is a constant source of discomfort. Even though the patient be too dull and toxic to ask for it, water should be given freely. One of the principles of treatment is to give water regu- larly and freely. Coughing due to bronchitis is a common, irritating, and ex- hausting symptom which must be relieved. Cold hands and feet, resulting from the low blood-pressure and poor circulation, are often a source of discomfort. A hot- water bottle should be applied. Retention of urine often occurs and should be looked for. It results from loss of muscular tone in the bladder due to the toxins and is a cause of abdominal pain and discomfort. The bladder must be emptied by nursing measures used to relieve retention or by catheterization. Abdominal pain, tenderness, and distention are distressing symptoms which must be particularly guarded against. They are due to the inflammation and ulceration of the intestines and to the loss of tone in the intestinal muscles. Distention may develop into the dreaded tympanites—dreaded because it pre- disposes to perforation and peritonitis and once developed is difficult or impossible to reduce. It is prevented by carefully regulating the diet, by giving plenty of water and preventing the accumulation of fermentation substances in the intestines by keeping the bowels open. Frequently a daily cleansing enema is given. The cold baths also help to prevent distention by im- proving the muscular tone of the intestines. Turning the patient also helps to prevent the accumulation of gas. Maintaining Vital Resistance by Proper Feeding is the third important factor. The diet is an extremely difficult problem and doctors differ widely in what they consider safe for the patient. 492 THE PRINCIPLES AND PRACTICE OF NURSING Some believe in a very low diet, almost starving the patient. This belief is based on the poor appetite, lessened secretions, the intestinal lesions and gastro-intestinal disturbances (such as diarrhea, constipation and distention), and the danger of hemor- rhage and perforation. Others believe in giving a high caloric diet—"as much food as the patient will take and handle well." This varies with the patient, depending upon the appetite, gastro- intestinal disturbances, and toxemia. This second method is based on the facts already discussed in the effect of starvation, of fever and toxins on tissue destruction with resulting emacia- tion, loss of strength, and lowered resistance. Furuncles, bed- sores and secondary infections are not so common when food is given. It is also based on the belief that, while in the early stages the loss of appetite and diminished secretion demand a limited diet, the body quickly recovers and can digest and assimilate food well. It is also based upon the fact that results by this method have been satisfactory. The high caloric diet is regulated by the following principles (Coleman): 1. That the minimum daily caloric requirement is 41 calories per kilo. 2. That the optimum daily caloric allowance is 60 to 80 or more calories per kilo, the average for a man weighing 150 pounds being 4000 calories. 3. That the minimum amount of protein should be given, sufficient to meet the body needs without taxing the tissues, the kidneys and other organs of elimination. 4. That fats should be given with care on account of the dif- ficulty in digesting them and their tendency to cause diarrhea and other gastric disturbances. 5. That carbohydrates are the most efficient energy pro- ducers and are the great protein sparers. The optimum daily protein allowance is 75 to 100 gm. The daily carbohydrate allowance is 250 to 800 gm. The daily fat allowance is 50 to 200 gm. The basal diet consists of milk, cream, eggs (raw, soft-boiled, or soft-poached), milk-sugar, stale bread, or toast and butter. Milk substitutes and milk preparations are used—buttermilk, kumyss, cocoa, whey, junket, custard and ice cream, etc.; strained gruels, boiled rice or macaroni, baked potato, apple sauce and liquids, such as lemonade, orangeade, tea and meat broths, etc., are also included in a high caloric diet. Whatever feeding is ordered by the doctor for the patient, the following principles must be observed by the nurse: All feedings must be given regularly and at stated intervals. The patient must never be forced but should be encouraged to take all the food allowed, the nurse remembering the importance of the diet in the patient's recovery. The fancies of the patient must be considered as far as possible; avoid things disliked, because they spoil the appetite and turn the patient against all nourishment. Note whether foods disagree or not; watch for a coated tongue, NURSING IN THE ACUTE INFECTIOUS DISEASES 493 nausea, a sense of fullness, distention or diarrhea, and examine the stools for curds of milk and for undigested fat. Milk diluted with lime water or vichy is more easily digested—adding a pinch of salt also makes it more palatable and more easily digested. Give sweet milk very slowly, a teaspoonful at a time to prevent the formation of solid curds. When sweet milk is not taken well, buttermilk may be given. It is more easily digested, causes less nausea, distention, and diarrhea, because the fat is removed and the casein is finely divided owing to the lactic acid present and the mechanical action used in removing the cream or fat. Milk sugar is used instead of cane sugar because less sweet (sweet things are always nauseating to sick people and even healthy people with slight indigestion say that "the thought of sweet things makes them sick"), and because it ferments less easily. With many, however, it causes nausea, vomiting and distention; watch for this effect. Cold weak tea will often settle an irritated stomach. Meat broths have no caloric value and should not be considered as nourishment given, but they are tasty and improve the appetite. See that they are properly seasoned and varied as far as possible. They must not be given if diarrhea is present. Lemonade, orangeade and imperial drink are grateful and refreshing to the patient. They relieve thirst, stimulate the flow of saliva and improve the appetite and diges- tion. They are a means of supplying water and sugar to the tissues; they help to keep the mouth in good condition and have both a laxative and diuretic effect. Water should be given at regular intervals whether the patient seems to be thirsty or not. Two or three quarts and more, if possible, should be given daily. When feeding the patient all exertion must be avoided. A glass drinking tube may be used, but if the patient is delirious or in a stuporous condition, he should be fed with a teaspoon. As a rule, patients are not awakened at night from a natural sleep for nourishment, but a dull, stuporous condition must never interfere with the regularity of the feedings. Alcohol is used, by some doctors, in some cases. It stimulates the mucous lining of the stomach and aids digestion. It acts as a food, being burned, with the production of energy. It quiets and soothes the toxic, overstimulated nervous system, relieves nervous tremblings, excitement, and sleeplessness, steadies and slows a rapid pulse, and causes the dry mouth and skin to be- come moist. "The Elimination of Effete Materials by the Kidneys, Bowels and Skin."—Every avenue of escape must be kept open for the elimination of toxins and other waste products. The skin is kept in good condition and elimination stimulated by giving plenty of water to drink, by cleansing baths, by cold sponge or tub baths, by alcohol rubs and massage and by general improvement of the circulation. The kidneys are stimulated and flushed, the toxins are diluted and eliminated by giving large amounts of water, lemonade and 494 THE PRINCIPLES AND PRACTICE OF NURSING imperial drink, etc The kidneys are rested by giving a mini- mum protein diet and aiding elimination by the skin and intes- tines. Cold sponge and tub baths stimulate the kidneys and aid elimination. Typhoid bacilli may be eliminated in large numbers in the urine, particularly if there is any interference with the proper flushing of the kidneys and in retention of urine. Urotropin is given as a urinary antiseptic. When retention of urine must be relieved by catheterization, extreme care must be taken to avoid infection, as the weakened bladder and lowered resistance make it very susceptible to infection by pathogenic organisms. Proper elimination from the bowels is extremely important. The intestine is the seat of the local lesions. Improper care may result in hemorrhage, perforation, distention or tympanites which not only causes pain and discomfort, but interferes with the breathing and action of the heart, and the distended, weakened wall predisposes to hemorrhage and perforation. The patient should be watched for symptoms of distention and the stools watched for the presence of flatus, undigested food and blood. A daily cleansing enema is frequently given—care must be taken to avoid force or pressure and exertion or straining on the part of the patient. The enema should be small and not high. Great care must be taken in the use of the bedpan, also to avoid exer- tion. When lying down, the elevation of the hips on the bedpan always causes some strain and difficulty in movement, so that in some cases (when hemorrhage and perforation are particularly feared), even this slight exertion is not allowed. A large pad is used in place of the bedpan. The recumbent position is always maintained unless otherwise ordered. If tympanites develops it is treated by the insertion of a rectal tube, carminative en- emata, the application of turpentine stupes to the abdomen and careful regulation of the diet. The Relief of Toxemia.—Toxemia may be very severe, par- ticularly in the second and third week, and may cause death. It is relieved by carefully regulating the diet, keeping up the resistance, giving plenty of water, aiding the elimination and by the use of cold air and cold tub or sponge baths. For the effect of the cold baths see the Brandt Bath, page 393. Complications to be Guarded Against.—Typhoid fever is not feared so much for itself but for the complications which are apt to develop. Without complications the fever runs its course and the patient usually gets well. It is, therefore, important to know how to guard against such complications, to recognize their symp- toms, and to know what to do should they develop. It is im- portant to remember that the height of the fever and the severity of the attack have nothing to do with the danger of complications, as they are just as likely to occur with a light attack. Good nursing does, however, help in lessening the danger of compli- cations. NURSING IN THE ACUTE INFECTIOUS DISEASES 495 The complications which may develop are a recrudescence or relapse, hemorrhage, perforation, cholecystitis, meningitis, phlebitis, thrombosis, pulmonary embolism, pneumonia, paro- titis, otitis media, mastitis, bone lesions and arthritis. The end of the second and during the third week is the most dangerous period, owing to the patient's weakened condition and lowered resistance. Necrosis, sloughing and ulceration of the intestinal lesions occur so that hemorrhage and perforation are particularly to be feared during this period. A sudden rise or fall in the temperature, or a sudden change in the pulse rate usually indicates complications. Chills may precede pleurisy, pneumonia, otitis media or parotitis, etc. Severe headache may indicate meningitis. The prognosis in hemorrhage or perforation is always very grave. A hemorrhage usually comes without any warning. The symp- toms are a sudden fall in the temperature, sometimes a sensation of sinking and at the same time or later, the appearance of blood in the stools. There may be pallor, cold extremities, clammy sweat, a rapid, thready pulse, restlessness and air-hunger. The treatment is to stop all food, keep the patient at absolute rest, moving him only when absolutely necessary, an ice-coil to the abdomen, and the administration of calcium lactate or an injec- tion of horse serum or human serum to aid the clotting of blood. Morphin may be given to insure absolute rest of the patient and of the intestines. No bowel movements are allowed for two or three days and then with caution. When the loss of blood is so severe as to deprive the vital centers and the heart, it should be treated like any other hemorrhage by elevation of the foot of the bed, heat to the extremities and transfusion, etc Perforation is even more dangerous than hemorrhage. The only hope for the patient is in its early recognition and imme- diate operation to close the perforation. It is due to ulceration or to distention with rupture of the weakened wall. It is most apt to occur in the third or fourth week. The symptoms are a sudden, sharp abdominal pain, a rapid rise in leucocytosis fol- lowed by the symptoms of general peritonitis—a rapid, thready pulse, rapid, shallow respirations, the temperature may fall, then rises, pallor, a pinched, anxious expression, cold, clammy sweat, persistent vomiting, local tenderness and rigidity. The symptoms and treatment of other complications are the same as when the diseases occur alone. Precautions to Prevent the Spread of the Disease.—The nurse should wear a gown and cap. Rubber gloves may be worn, if not, the nurse should carefully scrub and disinfect her hands after each treatment. When giving a tub bath a rubber apron should be worn. After waiting on the patient the nurse should avoid touching anything with her hands before disinfecting them, and should be particularly careful before going to meals and should avoid touching her face with her hands. The patient should be covered with screens to protect from 496 THE PRINCIPLES AND PRACTICE OF NURSING flies, both for his comfort and to prevent the flies from spreading the infection. All the utensils to be used for the patient—dishes, tray, cut- lery, bath tub, thermometer, bedpan, urinal, rectal tubes, etc.— should be carefully marked and isolated. They should be dis- infected after use. All the bedlinen and gowns, etc., used for the patient must be disinfected. All discharges from the patient, the urine, stools, sputum, vomitus and bath water—must be disinfected. When the pa- tient has involuntary movements, the nurse should be particu- larly careful in caring for the patient and in the disposal of the stool and linen, etc. Oakum pads are usually used under the patient. The nurse should wear rubber gloves throughout the procedure and in washing the linen even after it has been disin- fected. The oakum pad with the stool should be securely wrapped in paper so that even rough handling in the garbage or sewage disposal will not scatter the stool and spread the infection. After the disease is over the bed, mattress, blankets, linen and utensils, etc., should all be thoroughly disinfected. Care of the Patient during Convalescence.—Convalescence usually begins in the fourth week, but the danger of heart failure and other complications must be constantly remembered. A recrudescence or relapse may occur in the fifth or sixth week. The diet is carefully regulated, eliminations promoted, and the pulse and temperature are carefully watched. All physical exer- tion and mental excitement are avoided until the temperature has been normal for at least a week. The same care regarding visitors, reading and conversation, etc., should be observed as during the disease. When the patient is finally allowed up he should be advised to move about slowly and avoid fatigue or mental excitement. Fresh air and sunlight are very important. Typhoid Fever in Children.—The disease is much the same in children as in adults, only the lesions are less severe. Necrosis and ulceration of the intestinal lesions are not so common, or if they occur are not so deep so that hemorrhage and perforation are not so common. Tympanites is common, and, as in the adult, is a very serious condition. The fever is less regular, runs a less typical curve, is higher and of shorter duration than in the adult. The nervous symptoms are apt to be severe and con- stant. The treatment and prophylaxis are the same as in the adult. Tests used in Typhoid Fever.—Examination of the Blood.—■ Blood cultures are taken for the purpose of isolating the organism. The cultures are usually positive during the first week. The Widal test is made to determine the presence of specific antibodies (agglutinins) in the blood. The test may be negative during the first week (when the blood culture is positive), but NURSING IN THE ACUTE INFECTIOUS DISEASES 497 by the second week it is usually positive, while the blood culture may be negative. A leucocyte count shows a leucopenia or decrease in the num- ber of white blood corpuscles (usually from 3000 to 6000). There is an increase in the lymphocytes and a decrease in the polymorphonuclear cells. An increase in the polymorphonuclear cells points to a complication such as pneumonia, peritonitis, or phlebitis, etc. Examination of the Urine.—The Bacillus typhosus may be found in the urine. The Diazo reaction is a test used which indicates the presence of the organism in the urine. Examination of the Stool.—Cultures of the feces show the presence of the bacillus in large numbers. They are most nu- merous during the second, third, and fourth weeks of the disease. PNEUMONIA Pneumonia is one of the diseases in which the nursing care is perhaps the most important factor. It must run its course, but skilled nursing care can do much to give comfort and pre- vent complications. Pneumonia is an acute infection of the lungs and is the most fatal of all the acute diseases. It is called lobar or broncho- pneumonia, according to the location of the pathological process in the lungs. The general principles of the treatment are the same in both conditions. In either case we have to consider a patient suffering from an acute infection and inflammatory pro- cess in the lungs, and from a marked general toxemia. The re- sulting consolidation and congestion of blood vessels not only interfere with the function of the lungs, but mechanically inter- fere with the action of the heart, throwing an increased burden upon it. The toxins of the disease also attack particularly the nervous system, the vital centers, the muscles of the heart and the blood vessels. The heart and blood vessels are both poisoned and overworked; the vital centers which control them are also poisoned, so that failure of the circulatory system is the great danger in pneumonia. Bronchopneumonia is more apt to attack the weak, infants, and old people, in whom the power of heat production is very low. It is also more apt to be accompanied by acute bronchitis in which cold air may be irritating and may increase the cough. The treatment must be modified in these conditions. Cold air treatment may be too severe. The general principles in the nursing care and treatment are much the same as in typhoid fever. Rest is absolutely essential. The patient must be spared every effort which means extra strain on the heart so that he may muster all his forces to combat the disease. Sudden movements are particularly to be avoided. He should be kept in the recumbent position with one pillow only, 498 THE PRINCIPLES AND PRACTICE OF NURSING unless difficulty in breathing makes this position impossible. When in the semi-recumbent or sitting position he must be com- fortably supported, prevented from sliding down and all causes of strain removed. He should be turned frequently, but never allowed to turn himself. Mental rest and quiet are equally essential; the patient knows he is ill, does not want to be dis- turbed, has enough on his mind, his attention being concentrated on the struggle to get enough air. The General Hygienic Care.—The choice and management of the room or ward, the bed, care of the body, prevention of bed- sores, and the care of the eyes, nose and mouth—are the same and equally essential with that in typhoid fever. The care of the nose, back of the nose and mouth is particularly important. Secretions must not be allowed to accumulate, as they interfere with breathing, are a source of discomfort and force the patient to breathe through his mouth. The mouth becomes dry, which adds to the thirst and loss of appetite, etc, and causes cracks and fissures to form. A neglected mouth, besides being a source of discomfort, is a real source of danger, resulting in sordes, fissures, interference with digestion and secondary infections such as otitis media, parotitis, bronchitis, lung infections and ab- scesses, etc. The diet varies with the length of the disease and the degree of toxemia. In lobar pneumonia, the patient is usually very toxic. The appetite is poor, digestion is impaired, and the course is very short, so that no attempt is made to force the diet. Fluid diet is given. Milk or its substitutes are the chief foods. Water is given in abundance and lemonade, orangeade, and imperial drink for the same purpose as in typhoid. When lobar pneu- monia is prolonged or when complications set in, also in broncho- pneumonia, which is more prolonged, efforts are made to increase the caloric value of the diet. The elimination of waste materials is extremely important on account of the absorption of waste products from the inflam- matory process and the tissue destruction due to the fever and toxemia. Elimination by the skin, kidneys, lungs and intestines is stimulated by cleansing baths, cold air or cold baths, abun- dance of water to drink, and drugs which stimulate the circulation or promote the action of the skin, kidneys or intestines. Elimi- nation from the intestines is extremely important on account of the great tendency to constipation and tympanites due to the toxic effect on the muscles of the intestines with stasis, fermen- tation and putrefaction. Tympanites interferes with the action of the diaphragm and adds greatly to the burden of the already distressed heart and lungs and favors congestion. It is prevented by cleansing enemata, by careful regulation of the diet with particular attention to the amount of fats and milk sugar. It is treated as in typhoid fever. The treatment for the relief of distressing symptoms is directed toward the regulation of the local inflammatory process in the NURSING IN THE ACUTE INFECTIOUS DISEASES 499 lungs and the general toxic effect on the nervous system, vital centers, heart and other organs. The symptoms to be relieved are pain, cough, fever, headache, delirium, restlessness and sleeplessness, dyspnea, and cyanosis. The complications to be feared and treated if present are pleu- risy (always present in lobar pneumonia), empyema, bronchitis, myocardial insufficiency, or vasomotor paralysis and pulmonary edema. The treatments consist in the application of cold, of heat, and other counterirritants, rest, position, and the administration of drugs. Coid is applied in the form of cold air, the cold chest compress, an ice cap, and cold baths. The Open-air Treatment.—The benefits of the open air—air which is dry, moving and variable in temperature, have already been explained in Chapter III. The reflex effect of cold, stimu- lating the nerve endings in the skin, and reflexly the vital centers controlling the heart, lungs, blood vessels and other organs, has also been explained. In pneumonia, in which a portion of the lung is completely incapacitated, the circulation interfered with so that the body cells are smothering for oxygen, and in which the vital centers, heart and other organs are poisoned by toxins, the beneficial effects of cold, open air are particularly valuable. The pulse becomes stronger and slower, the appetite is improved and cyanosis, headache, delirium, restlessness and sleeplessness are relieved. Only the face should be exposed. The patient should wear a hood and be carefully protected from winds and drafts. The extremities and body, particularly the shoulders, should be kept snug and warm with extra clothing and a hot water bottle at the feet. If the body and extremities become chilled, the congestion and above symptoms will be increased. The patient is moved indoors for examinations, bathing, use of the bedpan and other treatments. A pneumonia patient should be closely watched constantly, and particularly when exposed to the cold air. A delirious patient may disturb the clothing and become chilled, or get out of bed or jump out of the window, or in some other way injure himself. Cold air treatment, if used for infants, the old and weak, must be used with the greatest care because their powers of producing heat and of reacting to the cold are poor. Cold is not used in acute bronchitis, as the cold is irritating and increases the cough. Coughing is always very distressing and exhausting. The cold chest compress may be used to relieve pain, and coughing due to pleurisy or bronchitis; to relieve congestion in the lungs, dyspnea and cyanosis and to act as a tonic to the heart. (See Chapter XXIV.) An ice-bag may be applied to the chest to relieve pain due to pleurisy or to act as a tonic to the heart. It is not used for the very young or very old. It is also applied to the head for the relief of headache, sleeplessness and delirium. 500 THE PRINCIPLES AND PRACTICE OF NURSING Cold Baths.—The cold sponge or cold pack is used to reduce the fever when very high and prolonged, to relieve toxemia and restore the vital centers. Heat sometimes gives more comfort and relief. Local appli- cations are made to the chest in the form of the cautery, poul- tices or fomentations. Steam inhalations give great relief in coughing due to bronchitis. Warm sponge baths sometimes relieve restlessness and sleeplessness. Other counterirritants—a mustard paste or dry cupping—are also used for the relief of pain, coughing and dyspnea. Strapping the chest with adhesive rests the lung, prevents fric- tion and relieves pain and cough due to pleurisy. Venesection is sometimes performed to relieve cyanosis, and dyspnea in strong, full-blooded patients, when the livid, bloated face and full, bounding pulse indicate venous congestion. The cyanosis is due to the pulmonary congestion and obstruction with backward pressure on the right side of the heart and veins. The withdrawal of blood takes the burden from the heart and pre- vents dilatation. Drugs.—Codein or morphin are sometimes given to relieve pain and coughing. They are also given to relieve headache, delirium, sleeplessness and restlessness. Bromids, veronal, tri- onal, and paraldehyd are also used for sleeplessness and rest- lessness—sleep is absolutely essential. Heart stimulants—caf- fein, camphor, strychnin, adrenalin—and respiratory stimulants —caffein, atropin, etc.—are given as required. Antipneumococcus serum is used as the specific treatment in Group 1 pneumonia. Antipneumococcus Serum.—The pneumococcus, the cause of pneumonia, occurs in four types or groups, all first cousins, so to speak, in one large family, each giving rise to a different type of pneumonia—Group I, II, III, or IV pneumonia. The diagnosis is made by an examination of the sputum and urine. Type I pneumococcus causes about from one-half to one-third of all the cases of pneumonia and the mortality has been about 25 per cent. Type II pneumococcus causes about the same number of cases with about the same mortality. Type III pneumococcus causes about 10 per cent, of cases, and the mortality rate has been as high as 50 per cent. Type IV pneumococcus causes about 20 per cent, of all cases of pneumonia and the mortality rate is about 12 per cent. The antipneumococcus serum *is of therapeutic value only in Type I pneumonia and it is said to have reduced the mortality from 25 per cent, to 10 per cent. The Method of Administration.—The serum is warmed to body temperature to prevent otherwise severe chills, and injected intravenously. The average dose for an adult is 100 c.c, which may be re- NURSING IN THE ACUTE INFECTIOUS DISEASES 501 peated every twelve or every six to eight hours until the disease is checked. The serum must be introduced very slowly and very grad- ually and the patient watched closely for any symptoms of unfavorable reaction such as sudden flushing of the face, rest- lessness and uneasiness, increased pulse rate, difficulty in breath- ing and urticaria with a possible serious collapse and fatal outcome. If the case permits the delay, an hour or two preceding the intravenous injection, an intracutaneous injection is frequently given and the area watched for a local edema and erythema which indicate that the patient is sensitive and that specal care must be taken in the use of the serum. In many cases serum sickness—urticaria, edema of the skin, joint pains, enlarged glands and a rise in temperature—may follow a week or two after the injection. The crisis in pneumonia, as the name suggests, is a very critical period due to the sudden drop in temperature, loss of heat, pro- fuse perspiration and relief of strain on the heart. Marked depression and collapse may occur with a weak, rapid pulse, subnormal temperature, cyanosis and cold, clammy sweat. The patient should be watched very closely when the crisis is due (which may be about the seventh or ninth day) and the nurse should help him through with careful nursing, by the applica- tion of external heat, by rubbing the extremities, etc., with warm alcohol to improve the peripheral circulation and by giving heart and respiratory stimulants as ordered. Patients with an alcoholic history require particular watchful- ness on the part of the nurse throughout the disease. They are more apt to suffer from heart failure and nervous symptoms and may develop delirium tremens. They are always thirsty and should be given abundance of water to drink. Water, nourish- ing diet, alcohol, and sedatives help to prevent extreme nervous symptoms. During convalescence the patient must not be allowed to sit up or allowed any unusual exertion without special orders from the doctor because of the danger of sudden death from failure of the weakened heart muscle. When allowed to sit up the pulse must be closely watched. Sudden death from pulmonary embolism is also to be feared because during convalescence reso- lution is taking place. Prophylaxis.—Nurses in caring for pneumonia patients should take particular care of their own health. They should be well nourished, take the proper amount of exercise, and should avoid fatigue, exposure, mental worry, common colds or anything likely to lower their resistance. The nose and mouth should be cleansed with an antiseptic frequently. The presence of adenoids, hypertrophied tonsils, and other abnormalities predisposes to an attack. Care should be taken to avoid the excretions from the nose and throat when the patient is coughing or sneezing, also 502 THE PRINCIPLES AND PRACTICE OF NURSING care should be observed when handling these secretions and sputum. When open-air treatment is used, the nurse should be warmly clad. Pneumonia in Children.—Bronchopneumonia comprises 75 per cent, of all the pneumonia in the first year. It is always very serious, although the outlook is better than in adults. Lobar pneumonia comprises nearly all the cases of primary pneumonia. The nursing care is much the same as in adults. When cold- air treatment is used, extreme care must be taken to protect from winds and drafts, and to see that the body and extremities are warm. Cold air is not used when bronchitis is present. When sponging young or feeble infants for fever, etc., extreme care should be taken to avoid exposure and chilling, as their powers of heat-production and of reaction are very poor. Fre- quent change of position is necessary; a young child may be held in the arms of the nurse. Circulatory failure is much less a cause for worry than in adults. Nervous symptoms—delirium, convulsions, meningismus (toxic irritation of the meninges) may be marked. Tests Used in Pneumonia.—Examination of the blood shows an increased leucocytosis, increased polymorphonuclears, and, in the early stage, a positive blood culture. Examination of the sputum shows the organisms present and the group to which the pneumococcus causing the disease belongs. ACUTE RHEUMATIC FEVER In the nursing care of acute rheumatic fever, we have to con- sider a patient suffering from an acute, local inflammatory proc- ess in the joints with excruciating pain, stiffness, and swelling and also from fever and general toxemia with pyrexia, thirst, loss of appetite, constipation, scanty, very acid urine and pro- fuse sweats having a sour odor. The complications to be feared are endocarditis, pericarditis, myocarditis, pneumonia, pleurisy, hyperpyrexia, and nervous complications—delirium, coma, stupor, prostration and chorea due to the concentration of the poisons on the nervous system. The room selected should be sunny, cheerful and well ven- tilated. The patient should be protected from drafts and from changes in the temperature. He should wear a flannel gown, and if he perspires freely should lie between blankets to prevent chilling from the drenching sweats and to avoid the clammy, sticky feeling of wet sheets. The shoulders should be well protected. The gown should be open down the front and sleeves (if the arms are involved) to allow applications with the least amount of disturbance. The care of the skin is extremely important on account of the sour odor and irritating quality of the acid sweats. The care of the buttocks is also important on account of the sweat and NURSING IN THE ACUTE INFECTIOUS DISEASES 503 acid urine. Alkaline baths, alcohol rubs and keeping the skin dry with powder will keep the skin in good condition. The care of the mouth is the same as in all fevers. The diet and care regarding proper elimination are also much the same. When the salicylates are given, constipation is par- ticularly to be avoided on account of the danger of acidosis. Rest, not only of the painful extremity, but of both mind and body, is absolutely essential. Cardiac complications are to be feared with the mildest attack. All causes of restlessness and sleeplessness are to be avoided. The disease is acute and apt to be prolonged so that the patient needs all his energy. The relief of pain is necessary to secure rest and sleep and if pain is not relieved, it will wear the patient out. Every move- ment may mean pain and even without movement the pain may be severe. Extreme care should be used in making the bed, in turning, lifting, or moving the patient, in the use of the bedpan, and in the application of treatments, etc Avoid even touching or leaning on the bed unnecessarily—the patient will often scream with alarm at the mere thought. A cradle is used to support the weight of the bedclothes. Pain is relieved by rest, position, the local application of heat, cold, counterirritation, and by the use of drugs. Pain insures rest. The patient instinc- tively assumes the most comfortable position, that is, semiflexion of the joint, as this relieves the pull of the muscles on the ten- dons and ligaments around the joint. Rest and the proper posi- tion are obtained by the use of pillows, or a well-padded splint or cast. The danger is shortening of the tendons and ligaments resulting in a stiff joint. Moderate movement is sometimes en- couraged to avoid this and extension with weights is sometimes used. Heat may be applied by simply wrapping the limb in lint, cotton or flannel bandages, or in the form of fomentations, the cautery, thermal light rays or antiphylogistin. Ultraviolet rays are also used. When applying heat, the joint should be protected from changes in temperature. Cold is applied in the form of an ice-bag, ice-coil or cold compresses. Various soothing lotions, such as lead and opium, or Fuller's lotion, etc., are frequently ordered. Methyl salicylate is applied as a rubefacient. Can- tharides may be used in the form of the fly blister. The drugs used chiefly to relieve pain are preparations of salicylic acid, which is antiseptic, antipyretic, and also anodyne. Commonly used preparations are sodium salicylate, aspirin, salicin and methyl salicylate. The salicylates lower the tem- perature, relieve pain and local inflammation and aid resolution. They may cause acidosis or marked symptoms of depression. A nurse should watch for their toxic effect indicated by buzzing, roaring in the ears, deafness, headache, skin eruptions, and gas- tric, cardiac, respiratory or cerebral disturbances. Drowsiness, dyspnea and vomiting point to acidosis. These drugs should be given well diluted. An alkali such as bicarbonate of soda is frequently given with the salicylates. It neutralizes the acid, 504 THE PRINCIPLES AND PRACTICE OF NURSING prevents gastric disturbances, and acidosis, and is said to pro- tect the heart. The nausea and pain, etc., are lessened if the drugs are given after the patient has had something to eat. Aspirin is practically insoluble in water or acids and so is said to pass through the stomach causing less irritation. Other drugs used to relieve pain and induce sleep are acetanilid, antipyrin, phenacetin (watch for their depressing effect on the heart with cyanosis and a weak, rapid pulse), veronal, morphin, and other sedatives. Swelling with fluid in the joint is sometimes relieved by a tight, flannel bandage and, if necessary, the withdrawal of fluid by paracentesis. Strict aseptic measures must be used to prevent infection of the joint. Hyperpyrexia (104° to 105°) with restlessness, headache, and delirium is relieved by cold baths or packs. If chorea is present the patient should have complete rest and isolation in a quiet, dark room and all causes of excitement should be avoided. Sedative baths or packs, chloral, bromids, morphin and arsenic are frequently given. Acute Rheumatism in Children is said to be the cause of practically all the heart diseases. It differs from that in the adult in that the joint involvement is less severe, sweating is less profuse, but the heart suffers more. Chorea is also more com- mon. Watch for twitching, fidgety, vague, jerky movements, The mental attitude is apt to be unstable so that the child is easily upset or excited and laughs or cries easily. Rest, quiet, and very careful nursing are essential. PART I I — B THE NURSING CARE AND TREATMENTS USED IN SURGICAL DISEASES INTRODUCTORY Nursing in a surgical ward appeals to every nurse. It is a life of absorbing interest with a strong human and dramatic appeal, a life of action, a series of events in which tremendous issues (life or death) are at stake and in which the nurse plays an important part. The ward exists primarily for the prepara- tion for, and the care of patients after undergoing an operation, and this responsibility belongs chiefly to the nurse. Every opera- tion involves a considerable degree of risk and danger and requires a great deal of courage on the part of each patient which, in the rush of routine work, we often fail to appreciate or recog- nize—even those of us who shrink from and have difficulty in gaining sufficient courage to take a disagreeable dose of medi- cine. It is an experience which often brings the patient close to death. This we should remember when preparing the patient and taking him to the operating room as well as in the after- care and it should make us realize the seriousness of our respon- sibility toward him for there is nothing more sacred than the life of another. The courage and cheerful or calm endurance with which most patients bear the sufferings following an operation are often heroic and to be able to do so much to relieve their sufferings and make them comfortable is one of the greatest sat- isfactions to every nurse. Their discomforts can nearly always be relieved by good nursing and this ability to get and see the results of one's work is most stimulating and inspiring. The feeling that one can do very little to help is often apt to be depressing. The character of the work itself is full of interest and satisfaction. The demand for alertness, coolness, resourceful- ness, knowing what to do and how to do it with skill and with- out loss of time, and to be in the midst of deeds of courage, to witness bright, cheerful, or calm endurance of pain or difficulties calls out and develops these characteristics in us. The nurses' duties consist in assisting the surgeon with exami- nations which aid in diagnosis, preparing the patient for opera- tion, caring for him after the operation and in complications which may develop, and also in caring for patients suffering from minor surgical conditions, accidents and emergencies. 505 CHAPTER XXX THE PREPARATION OF A PATIENT FOR A MAJOR OPERATION THE EXAMINATION OF THE PATIENT The examination of the patient previous to the operation usually includes the following: A physical examination of the chest and part of the body affected, upon which the operation is to be made, always pre- cedes an operation. In operations upon the pelvic organs, an examination of special organs, by means of the rectum or vagina, may be necessary. The examination of the chest is for the pur- pose of finding out the condition of the heart and lungs. The condition of either the heart or lungs may contra-indicate an operation altogether or may determine the kind and method of anesthesia to be given, or may indicate that it would be advis- able to delay the operation until the condition may be improved by medical treatment. A diseased heart would probably not stand the strain and shock of the operation and an inflammatory disease of any part of the respiratory tract, owing to the irri- tating effect of the inhaled ether, would probably develop into a very severe, possibly fatal pneumonia. Exophthalmic goiter is another disease which frequently re- quires medical treatment until the condition is so improved that the operation may be carried out with safety. In this disease, also, special care is taken to partially or completely anesthetize the patient before going to the operating room and to "steal the gland" by not allowing him to suspect the possibility of an opera- tion or at least to have any suspicion as to the time set for it. Examination of the Urine.—When on an examination of the urine, albumin is found, indicating inflammation and an inability of the kidneys to function normally, the operation is usually delayed until this condition, by medical treatment, is .relieved. The toxic effect of the ether and of other incomplete products of metabolism which the kidneys are forced to eliminate, together with the shock, loss of blood, exposure during the operation, and the lowered resistance of the patient, would probably so increase the irritation and work of the kidney as to cause an acute attack of nephritis. Complete suppression of waste and toxic products in the body might follow, resulting in uremic poisoning, and possibly, convulsions, coma and death. When sugar is found in the urine, indicating that the patient 507 508 THE PRINCIPLES AND PRACTICE OF NURSING is suffering from diabetes, the operation is delayed (if at all pos- sible) until this condition is relieved. When acetone, diacetic or fi-oxybutyric acid (the acetone group) is found in the urine, it indicates that the patient is suf- fering from acidosis. The operation will be delayed until the condition has been relieved. Examination of the Blood.—A "blood-sugar" test or an ex- amination of the blood for sugar may be made. The normal amount of sugar in the blood is from 75 to 120 milligrams of sugar in 100 c.c. of blood. An increased amount indicates that the patient is suffering from diabetes. Sometimes the blood- sugar is increased without sugar appearing in the urine. The presence of sugar in the urine or the increased blood-sugar indi- cates faulty metabolism. If the operation were performed the increased amount of sugar in the blood would so interfere with the metabolism of the tissues that the wound might not heal. Increased sugar in the blood also causes arteriosclerosis and ar- teriosclerosis narrows the size of the blood vessels and even com- pletely closes some of them so that the nutrition of the tissues is greatly interfered with. This is the cause of gangrene in dia- betes. In diabetes, also, the resistance of the tissues is very low so that they are very susceptible to infection. If by medical treatment the urine can be made sugar-free and the blood-sugar reduced, the operation may be performed with safety. A carbon dioxid test or an examination of the blood to find the volume per cent, of carbon dioxid may be made. The per cent, of carbon dioxid is an indication of the alkalinity reserve in the blood plasma. When the percentage is below 50, it indi- cates that the patient is suffering from acidosis. When the per- centage is as low as 20 per cent, the patient is approaching the stage of coma. Acidosis may occur alone or more frequently with diabetes. It indicates faulty metabolism, the incomplete oxidation of fats, resulting in an accumulation of fatty acids (diacetic acid, etc), which are highly toxic and result in coma and death. The toxic effect of the ether may aggravate a mild form of acidosis into acute acidosis which might prove fatal. The condition may be relieved before the operation by medical treatment. A blood examination may be made to determine the hemoglobin percentage. The normal hemoglobin is from 85 to 110 per cent. If low, it shows that the patient is anemic, the vitality low and his resistance poor. Such a patient is a poor surgical risk. An operation would still further lower his resistance so, when pos- sible, will be delayed until the condition is improved. A white blood cell count or a total leucocyte and differential count is usually made before an operation, particularly when it is necessary to determine whether the patient should be operated upon immediately, or not, that is, whether it is an "emergency" case or not. The total leucocyte count means the total number PREPARATION OF PATIENT FOR OPERATION 509 of white blood cells, which normally varies from 5000 to 10,000 per cubic millimeter of blood. A differential count means the percentage of the different types of white blood cells which make up the total. An increase in the total number of leucocytes is called "leucocytosis," and in a surgical condition, indicates in- flammation and suppuration in some place in the body. The polymorphonuclear type of leucocyte (normally forming from 65 to 75 per cent.) would in this condition be the white cell in- creased. For instance, if an appendiceal abscess were suspected, a surgeon would probably operate immediately if the leucocyte count and percentage of polymorphonuclear cells were increased, in order to prevent a rupture of the abscess and spread of the infection to a general peritonitis. A leucocyte count may be taken after an operation also. It should return to normal in a few days. If not, it may indicate that the wound has become infected, or that it is not draining properly, or that some complication has set in, such as peritonitis or pneumonia. If the count is lower than normal, it indicates that the patient's resistance is low. The Clotting Time of the Blood.—Normally the blood clots in from two to eight minutes. In some diseases, hemophilia, leuke- mia, and diseases of the liver, gall bladder or ducts which cause a backward flow of bile into the blood, the blood may take much longer to clot so that during or after an operation the patient may lose a great deal of blood before the bleeding can be stopped. Again in certain operations on the liver, spleen, gall bladder, and kidneys, and in tonsillectomy, etc., there is always an increased danger of a hemorrhage. In the above conditions, if suspected, and before certain operations, it is particularly important to find out the clotting time of the patient's blood. If this is longer than normal, for several days before the operation the patient is usually given calcium lactate and either human or horse serum to aid in the clotting of the blood. The blood-pressure.—The blood-pressure is measured because patients with a high blood-pressure or any circulatory disturb- ance do not stand the strain and shock of an operation well. Efforts are usually made to reduce it by medical treatment before an operation. PREPARATION FOR A PHYSICAL EXAMINATION In assisting the doctor with an examination, the duties of the nurse are to prepare the patient and the necessary articles, to assist the doctor, and to make the patient as comfortable as pos- sible before, during, and after the examination. In all examinations the following are the essential things to be considered: Preparation of the Patient.—The patient's comfort, both mental and physical, is the nurse's first consideration. An ex- amination is always a trying ordeal to the patient, particularly 510 THE PRINCIPLES AND PRACTICE OF NURSING when a rectal or vaginal examination is necessary. It is made by a strange doctor, who is assisted by a strange nurse, and before the patient has had time to become adjusted to new surround- ings. The uncertainty as to what the doctor is going to do and the fear of exposure add greatly to the patient's discomfort. This the nurse, by her manner and tact, her knowledge of the condition and of what is required, together with her skill in pre- paring the patient, can do much to relieve. Nervousness inter- feres with a proper examination. It interferes with breathing, with the natural body position, and causes all the muscles of the body to contract. For all examinations it is necessary for the patient to be completely relaxed. The necessity for the ex- amination should be explained to the patient. Her confidence should be gained, and she should be assured that no unnecessary exposure will be allowed. A woman should never be embar- rassed by being left alone with the doctor. To avoid this the nurse should see that everything necessary is at hand. This is particularly important when a rectal or vaginal examination is to be made. The preparations should be made quietly, naturally, without any fuss or undue haste, which leaves the patient with the feeling of being only half prepared. On the other hand if prepared too long ahead, the suspense of waiting is apt to add to the nervousness of the patient. The room should be warm, as in all examinations some ex- posure is necessary. Cold and chilling cause the muscles to con- tract and make thorough relaxation impossible. It should be absolutely quiet so that the sounds heard in auscultation and percussion may be distinctly heard. A good light is necessary for thorough inspection. The upper bedclothes should be turned back neatly and smoothly, and arranged so that no bulk or weight interferes with the examination or the patient's comfort. The patient, his gown and bedclothes, should be scrupulously clean. Nothing is more embarrassing than to turn down the clothing and find the patient, his gown or undersheet, soiled or stained. The part to be examined should be exposed only during the immedi- ate examination. The top sheet may be used to cover the chest or an extremity, until the examiner is ready. A towel or a square of soft blanket may be used for this purpose. When the extremities are to be examined the clothing should be arranged so that one or both legs may be examined separately or together and without unnecessary exposure. When the abdomen is to be examined the top sheet, when turned down, should be tucked in firmly under the thighs so as to avoid displacement and expo- sure. The patient's gown should be turned back neatly to the waist and tucked in smoothly and neatly under the body. A blanket, if necessary, should cover the chest and the abdomen also until the examiner is ready. When the chest is to be ex- 'amined it is usually necessary to remove the gown entirely in order to inspect thoroughly the chest development and move- ments in breathing and for auscultation and percussion. It PREPARATION OF PATIENT FOR OPERATION 511 should be folded neatly, kept warm, and replaced as soon as the examination is completed. During the examination the patient's shoulders and arms and the part not under immediate examina- tion should be kept covered. The part should be covered during consultations. The clothing should always be replaced immedi- ately after the examination is completed. When an examination of the pelvic organs is to be made in which a rectal or vaginal and abdominal examination are nec- essary, the bulky upper bedclothes may be fanned down to the foot of the bed or if necessary they may be removed and replaced by a blanket and suitable draping. When the examination is made on a special examining table, in addition to the blanket and draping the patient usually wears a gown, dressing gown, slippers and stockings (laparotomy stock- ings) which reach to the thighs. A foot stool and the assistance of the nurse are necessary in assisting the patient to get on the table. The position of the patient depends upon the purpose of the examination and the part to be examined. The correct position is essential for an accurate thorough examination. This position should be made as comfortable and free from strain and effort on the part of the patient as possible. Complete relaxation is desirable. The following are the positions commonly used. To examine the anterior chest, the doctor may prefer to have the patient lie fiat on his back with arms lying loosely at the sides and one pillow only under the head, so as not to distort the position of the chest or interfere with breathing. When able, the patient may be requested to sit upright. He should be sup- ported by the nurse if necessary, and his back, arms and shoul- ders protected from cold or exposure. When examining the sides the arms are held loosely above the head. In examination of the posterior chest the patient may be sitting up leaning forward, supported by the nurse with his arms crossed in front or extended and resting on his knees. Pillows should be pressed snugly against the lower back for support. When unable to sit up the patient is turned on his side inclined toward the anterior chest and with arms loosely extended above the head. During an examination of the chest, especially when the patient is asked to count, or cough, the nurse should direct the patient to turn his head aside. A towel should be held between the doctor and the patient, but this must not be allowed to interfere with the examination or the patient's breathing or comfort. In auscultation the doctor may listen directly to the chest sounds by placing his ear against the chest. An "auscultation towel" made of thin muslin is first placed over the chest. If this towel is removed and replaced.on another area for auscultation be sure that the same side is placed next the patient. When the chest is hairy it may be necessary to moisten it with warm water in order to prevent the sounds heard with the stethoscope from being obscured by the friction of the stiff hairs against it. For an examination of the abdomen, the patient should lie flat 512 THE PRINCIPLES AND PRACTICE OF NURSING on his back with legs extended, arms lying loosely at the sides, and one flat pillow under the head. In an examination of the pelvic organs preceding an operation frequently a digital rectal or vaginal examination is necessary in addition to the examination of the abdomen. Provision must be made so that both palpation of the abdomen and a vaginal examination may be made together. For this purpose special positions (and special draping) are necessary. The following positions are those most frequently used: The Horizontal Recumbent Position.—In this position the patient lies flat on her back with legs together and extended or slightly flexed to relax the abdominal muscles. One pillow only is allowed under the head. The arms may be crossed on the chest or lie loosely at the side of the body. The Dorsal Recumbent Position.—This position resembles the above except that the legs are slightly separated, the thighs are flexed upon the body, and the legs upon the thighs so that the soles of the feet rest upon the bed. If the patient is placed on a special examining table the feet rest on the extensions provided for them, and the patient's buttocks are brought to the extreme edge of the table. When there is no special table sometimes the patient is placed across the bed so that her buttocks are at the extreme edge of the mattress and her feet are supported on a stool or chair. A board may be placed under the mattress to make it firm and even. This position is the one usually used for vaginal inspection or digital examination. The surgeon usually stands on the patient's right in order to use his right hand for examination. The Dorsal Elevated Position.—This position is the same as the above except that pillows are placed under the head and shoulders so as to further relax the abdominal muscles. This is sometimes necessary for a proper bimanual examination of the pelvic organs. The Dorsal Lithotomy Position.—The word lithotomy comes from two Greek words, lithos, meaning stone and tome, incision. The position was called lithotomy because used for the removal of stones from the bladder. This position is the same as the dorsal recumbent except that the legs are well separated and the thighs are acutely flexed on the abdomen and the legs on the thighs. The buttocks are brought to the extreme edge of the table or a little beyond. To maintain this position and further separate the legs upright rods with stirrups attached are fastened to the sides of the table, the legs are sharply flexed backward and each foot is passed to the outside of the rod and fastened in the stirrup. A pillow or sandbag is sometimes placed under the hips to elevate the pelvis. The sandbag is better as it gives a firm, unyielding support. When an examination is made with the patient in bed one or two nurses may be necessary to support the legs and hold the knees apart and immovable, or a folded sheet may be passed under the knees and fastened behind the PREPARATION OF PATIENT FOR OPERATION 513 shoulders. This position is used for cystoscopic examination of the bladder, for examinations of the perineum, vagina and cervix, and for digital examination of the pelvic organs through the vagina. It is also used for operations on the perineum, vagina, cervix, bladder, and rectum. Sims' or Left Lateral-Prone Position.—In this position the patient lies on her left side obliquely across the bed or table. One small pillow is arranged under the head so that the patient's left cheek rests comfortably upon it. Her buttocks are brought to the edge of the mattress. Her left arm is then drawn behind her back and her body inclined forward so that she lies partly on her chest. Her right arm lies in front in a comfortably flexed position. The thighs are flexed, the right one more so than the left. The knees are also flexed, the right more so than the left, so that it crosses the left and rests on the bed. When in this position the orifice of the vagina is clearly visible and the pelvic viscera fall forward. Sometimes a pillow is placed under the hips or between the knees to further expose the vaginal orifice. This position is used for examinations and treatments of the cervix and vagina. The Knee-chest or Genu-pectoral Position.—As the name im- plies, when in this position the patient rests on her knees and chest. The head is turned on one side with the cheek resting on a pillow. The arms should be extended, flexed at the elbows and resting on the bed so as to partially support the patient, or they may be clasped above her head. They are never allowed under her. The patient rests on her knees which are slightly separated. The legs are extended, the thighs being vertical and at right angles to them. A small pillow may be placed under the chest but the abdomen remains unsupported. The abdomen is not allowed to rest against the flexed thighs because the object of this position is to cause the pelvic organs to fall forward. It is used for examinations of the bladder, vagina or rectum and some- times for rectal irrigations. The Standing or Erect Position.—The patient usually stands with one foot resting on the floor and the other on a low stool or the round of a chair, the legs being separated as far as com- fort will allow. One hand usually rests on the hip, while the other (corresponding to the foot which rests on the chair) rests on the back of the chair for support. This position is used chiefly in vaginal examinations to determine the presence or degree of a prolapsed uterus. The Trendelenburg Position.—This position is not used in the ward for the purpose of examination. It is used in the operating room during operations on the pelvic organs in order to displace the intestines from the pelvis into the upper abdomen. A spe- cial table is necessary which can be adjusted so that the patient's head is low, her shoulders held by shoulder supports attached to the table, her body on an inclined plane and her knees flexed over the adjustable lower section of the table which is lowered. 514 THE PRINCIPLES AND PRACTICE OF NURSING The legs are fastened to this lower section to further prevent the patient from slipping. The method of draping the patient in the above positions differs somewhat in different hospitals but in all the following rules should be observed: The draping should be arranged so as to avoid all unnecessary exposure but at the same time so as not to interfere with a thor- ough examination. It should be loosely arranged so as not to outline the patient's figure unnecessarily and to allow a change of position quickly, but it should be securely fastened in place so that the necessary movements of the patient will not displace it. Only the part to be examined should be exposed, and that only during the immediate examination. Sometimes no exposure is necessary. Provision must be made for examination of the abdomen simultaneously with the digital examination of the vagina. In some hospitals special sheets are provided for drap- ing. Otherwise two or more sheets will be necessary usually. Laparotomy stockings are also used. As stated previously pro- vision must be made for keeping the patient warm. A screen is placed around the bed. When preparing the patient for a vaginal examination see that the external genitals are scrupulously clean. Sometimes the examination is preceded by a vaginal douche but it is usually omitted for the first examination so that the doctor may see the nature of the discharge. The bladder and bowels should be emptied. The uterus is between the bladder and rectum so that its position is altered when these organs are distended. The purpose of the examination may be to detect malpositions of the uterus or the presence of growths, the signs of which are obscured by contents in the rectum or bladder. An enema may be neces- sary if the bowels have not moved within the preceding twenty- four hours. The Articles Required for a Physical Examination.—For a vaginal examination the articles usually required are a pair of sterile gloves (the right glove only may be necessary), a sterile lubricant, a bivalve, Sims' or other variety of speculum and a uterine sound. If a local application is to be made or packing is to be removed or inserted in addition to the above the follow- ing articles will be required: uterine forceps, an applicator, absorbent cotton, sponges, a sponge holder, dressing forceps, tam- pons or a tube of gauze packing, scissors, the lotion to be applied and a basin for the packing or soiled instruments. All the instru- ments and other articles used must be sterile. The instruments used should be warm. A good light is always essential. Usually an artificial light and a head-mirror for the examiner are necessary. PREPARATION OF THE PATIENT FOR OPERATION The general mental and physical preparation has been dis- cussed in Chapter XVII. The preparation of the field of opera- PREPARATION OF PATIENT FOR OPERATION 515 tion is a more advanced procedure requiring wider knowledge and skill. More experience in aseptic measures is required and an understanding of the parts which may be involved in the operation. The part is often very tender and painful, the patient is often nervous, restless, exhausted, and in a critical condition. It is important not to tire or alarm him so that gentleness, speed, sureness of touch, and skill are essential. Preparation of the Field of Operation.—This preparation varies in different hospitals and also with different surgeons in the same hospital. The preparation used until within the last few years by all surgeons and which is still used by many is called a wet antiseptic dressing and consists of shaving, a thor- ough cleansing, with repeated or continuous disinfection of the part. The morning before the operation the patient is given a full bath and the wound area, and as much of the surrounding area as is likely to be exposed on the table, are closely shaved. Shav- ing requires considerable skill in order not to cause pain and dis- comfort or to tire the patient out. First see that she is in as comfortable a position as possible, that the clothing is arranged to avoid unnecessary exposure both in order to avoid chilling and in consideration of the patient's feelings. Never attempt to shave without a good light. See that the razor is sharp and use a good lather. Be very gentle but hold the flesh firmly so that the skin is stretched, smooth and free from wrinkles or creases. Shave well between the folds. See that the whole area is shaved close and clean. Be very careful not to cause pain or to make abrasions which alarm the patient and cause discomfort. Work as quickly as possible so as not to tire the patient. Be ex- tremely careful when the part is painful or the skin stretched and tender, as in peritonitis, or marked distention, or where there is local tenderness, as in appendicitis. Frequently the prepara- tion is omitted until the patient is under the anesthetic This part of the preparation is an unsterile procedure. After its completion all the articles used are removed, cleansed and put away in their proper places. The razor must receive careful attention. It should be cleansed immediately. In cleansing wipe toward and not away from or over the blade so as not to injure it. Do not let it touch a hard surface. If necessary to disinfect it, cover it with alcohol. Never use bichlorid of mer- cury as it corrodes metal. The patient is then prepared for the sterile preparation or disinfection of the part. The necessary articles are brought to the bedside and the bedclothing, etc., arranged neatly and conveniently without unnecessary exposure. The nurse must either have an assistant to drape the patient, open packages, or bottles and pour solutions, etc., or must pre- pare them so that she can carry out the procedure without con- taminating her own hands which must be kept sterile. Preparation of the Hands.—When her preparations are com- pleted, before proceeding with the sterile procedure the nurse 516 THE PRINCIPLES AND PRACTICE OF NURSING must "scrub up." The hands and arms are scrubbed to the elbow with a brush, soap and running water for 5 minutes, paying par- ticular attention to the nails and between the fingers. The nails should be short and cleansed with an orange stick. The hands and arms are then thoroughly rinsed, all the soap being removed with running water and are then immersed to the elbow in a dis- infectant solution, usually bichlorid of mercury 1:2000 for 3 minutes. The soap must first be thoroughly removed otherwise the bichlorid of mercury will combine with it forming a new compound having no disinfectant action on the skin. In wash- ing or removing the hands from the disinfectant always allow the water to run from the hands down over the elbows and not from the elbows over the hands as the hands or fingers must come in contact with the sterile articles used. The hands may then be dried with a sterile towel or may be left moist. They must not come in contact with anything unsterile. The area to be disinfected is then surrounded with sterile towels. It is then cleansed first with a sterile wipe saturated with tincture of green soap which is poured from the bottle by an assistant or by the nurse herself holding the bottle with a sterile wipe (the cork having been previously removed, the rim cleansed and covered with a sterile wipe). Throughout the pro- cedure, in cleansing and disinfecting the part, the region where the incision is to be made should be cleansed first, always work- ing from this point toward the circumference, and never touch- ing the point of incision with a wipe used on another part, and, therefore, not sterile; germs must be carried away from, and not toward, the part. Solutions must be poured on a sterile wipe or sponge and never directly over the part—this is uncomfortable to the patient and wasteful. The soap is then washed off with hot sterile water, using the same precautions, then with ether to remove all the soap and other greasy substances. After this it is washed off with alcohol 70 per cent, and with another disin- fectant, usually a hot solution of bichlorid of mercury 1:2000. The part is then covered with a dry sterile towel or frequently it is first covered with a sterile towel wrung out of a hot solution of bichlorid of mercury. The dressing is held in place by a binder or bandage securely fastened, to prevent it from slip- ping and so unsterilizing the part. For the same reason, the patient must be careful in moving about. This preparation is made about 12 hours before the operation. Sometimes the routine practice requires that the sterile preparation be repeated on the morning of the operation. Sometimes (especially when the part is dirty and requires special cleansing), after the first shaving and cleansing, a soap poultice, that is, gauze or a towel wrung out of a 12 per cent, hot solution of green soap, is applied and left on for several hours or over night and on removal, the usual sterile preparation follows. Another practice in use is the sterile preparation as described, but, six hours before the operation, the part is thoroughly dried PREPARATION OF PATIENT FOR OPERATION 517 with a sterile towel and painted with iodin 3.5 per cent. The iodin is allowed to dry and the part is covered with a dry sterile towel and binder or bandage. Advantages and Disadvantages of the Wet Dressing.—The part is thoroughly cleansed and it is thought that the hot moist applications soften the skin and tissues, promote perspiration and bring the bacteria to the surface where they can be acted upon by the disinfectant. The disadvantages of this elaborate preparation are that it causes the patient considerable discom- fort and inconvenience so that she is fatigued and the "fuss" is rather alarming. The softening of the tissues, and the lowering of the tone of the blood vessels lower their resistance, make them more susceptible to infection and the sodden condition causes them to heal less readily. It does not remove the bacteria as it is absolutely impossible to make the skin sterile. Some believe that it merely stirs them up and that the less they are disturbed the better, that it is better, so to speak, to "let sleep- ing dogs lie." The applications are difficult to keep in place and the whole preparation takes a great deal of a nurse's valuable time. The Iodin Perparation.—Because of the disadvantages of the above method, because many surgeons consider it unnecessary, and because iodin is the best disinfectant, causing the least amount of irritation to the skin, most surgeons have adopted the following method. The part must be clean and shaved as closely as possible, and that is all until the patient goes to the operating room. The area is painted with iodin after the patient is on the operating table. Some surgeons require an application of iodin to be made in the ward. This is allowed to dry and is then covered with a dry sterile towel held in place with a binder or bandage securely fastened. Precautions in the Use of Iodin.—In using iodin, it must be remembered that tincture of iodin is not a real tincture but merely a solution of iodin in alcohol, and that alcohol evaporates readily, so that if the iodin solution is not fresh or has been exposed to the air it becomes more concentrated, a stronger preparation which may burn the patient. Again iodin must never be applied to a moist surface nor moist towels, etc., be allowed to touch it after it is applied, because it will then surely cause a blister very difficult to heal. Its disinfectant effect is also interfered with. All perspiration or moisture of any kind must first be removed. Sometimes ether is first applied. It removes greasy substances, and, as it evaporates quickly, dries the part. Benzine is also sometimes used for the same purpose. Benzine is non-aqueous, evaporates, and dries the part. When applied, iodin must first be allowed to dry thoroughly before putting on the sterile towel. Avoid using too much as it is an irritant and will produce a burn. The skin should be a uni- form light brown. The excess iodin may and should always be removed with alcohol, as iodin dissolves readily in it. Remove 518 THE PRINCIPLES AND PRACTICE OF NURSING by mopping the part; never rub. After the operation the iodin should always be removed. In some hospitals it is removed with sponges saturated with starch water which combines chemically with the iodin, forming a new substance. A very important point to remember when using iodin is that it acts differently on different patients. The tissues of some are very sensitive to it. I have known of two cases in which gan- grene resulted from the use of iodin; in one, gangrene of the foot from an application for bunions, in the other, gangrene of the abdomen from iodin used as a preparation for an operation. An Emergency Preparation.—When the patient must be taken to the operating room immediately or within a few hours after admission, no soap or water must be used on the skin in shaving or cleansing. A "dry" shave is given and the iodin (7 per cent.) is either applied in the ward or in the operating room, or in both. Advantages of the Iodin Preparation.—The advantages of this preparation are that the patient is inconvenienced, worried, and fatigued to the least possible extent. Iodin is a powerful disinfectant. It penetrates more thoroughly than others, but is less irritating to the tissues, and if any should be absorbed, does no harm. It is also stimulating to the skin. The results of its use are entirely satisfactory as wound infections seldom occur. CHAPTER XXXI THE NURSING CARE AND TREATMENTS USED FOLLOWING AN OPERATION The general care of the patient has already been discussed in Chapter XVII. Although the discomforts which are apt to follow —headache, backache, thirst, nausea, and vomiting, distention, restlessness, sleeplessness and retention of urine—can very often be relieved by the simpler nursing measures and treatments, such as the application of cold compresses, poultices, stupes, and enemeta, etc., frequently other measures are necessary. Such treatments are colon irrigations, to relieve distention; a lavage, to relieve nausea, vomiting, or distention; a Murphy drip or proctoclysis, to relieve thirst; rectal feedings, to rest the stomach and supply nourishment to the body; catheterization of the bladder, to relieve retention of urine, and a bladder irriga- tion, if necessary, to relieve cystitis. These treatments will be discussed in the present chapter. They require more knowledge, experience, and skill than those already discussed, so are not usually entrusted to less experienced nurses. A COLON IRRIGATION OR ENTEROCLYSIS The word enteroclysis is derived from two Greek words; enteron, meaning intestine, and klysis, a washing out of stagnant or waste material. In a colon irrigation a large amount of fluid is injected, suf- ficient to distend the entire colon. It is intended to reach the ileo-cecal valve. Anatomical and Physiological Factors to be Considered in Giving the Treatment.—The large intestine begins at the ileo- cecal valve and extends to the anus, consisting of the cecum, the ascending colon (about 5 inches long), the hepatic flexure, the transverse colon (about 20 inches long), the splenic flexure, the descending colon (about 8% inches long), the sigmoid colon, and the rectum. The colon surrounds or frames from right to left the small intestines and is closely associated with the liver and gall bladder, the stomach and spleen, while the ascending and descending colon are in front of the kidneys. A hot solution in the colon therefore acts as a local application of heat to the above organs. "An injection of this kind goes into the very heat* citadel of the body, and if too cold, as it often is, produces dan- gerous chilling of organs which are ordinarily especially pro- 519 520 THE PRINCIPLES AND PRACTICE OF NURSING tected from cold by the omental apron and intestines" (Hare). The normal capacity of the colon in an adult is about nine pints. Its diameter decreases from above downward (from 3 inches in the cecum to D/2 inches at the sigmoid flexure) but it is capable of enormous dilatation if produced gradually. The movements in the large intestine are (1) peristalsis, carry- ing the contents on toward the anus; (2) antiperistalsis or retroperistalsis, carrying the contents backward toward the ileo- cecal valve so that fluid injected into the rectum may be carried to the ileo-cecal valve but cannot pass beyond. Woolsey states that "when the cecum and colon are distended the flaps of the >DREN»L GLAND LEFT RENAL VEIN PSOAS MUSCLE (EX- TERNAL border) Fig. 125.—Showing Relation of the Colon to the Kidneys and Other Organs. Liver, stomach and small intestines have been removed. (Semi-diagrammatic.) (From Woolsey's "Applied Surgical Anatomy," Lea and Febiger, Publishers.) valve are pressed together, preventing regurgitation into the ileum." "In an ordinary high enema the valve renders impos- sible the passage of the fluid into the ileum, but if a high pres- sure is steadily continued the fluid may pass the valve, though probably not before peritoneal laceration and other damage to the large intestine have occurred." Therefore it is not safe to use force and "an ordinary high enema causes the emptying of the lower ileum by stimulating its peristalsis so that there is no need to try to force an enema beyond the valve." The passage of the contents in the large intestine is slow, as may be seen in the accompanying illustration. Food begins to appear in the cecum 4y2 hours after being swallowed; that is, it begins to leave the stomach y2 hour after being swallowed and TREATMENT FOLLOWING AN OPERATION 521 passes through the small intestine (231/2 feet) in about 4 hours. It takes about the same time (4 hours) to pass from the ileo- cecal valve to the splenic flexure, a distance of about 2 feet. In constipation and other diseased conditions the passage may be delayed causing marked dilatation of the whole colon with the production of gases and toxic products. There is considerable absorption normally in the large intestines, particularly in the cecum and ascending colon. The contents entering the cecum contain 90 per cent, water, while normal feces when passed are formed or semi-solid, so that large amounts of fluid may be absorbed when a colon irrigation is given, particularly if given under a slight pressure. In chronic constipation and other common pathological conditions affecting the intestine the toxic products formed are also being absorbed. Conditions and Purposes for which Colon Irrigations are Given.—1. After operations for the following purposes: (a) To thoroughly cleanse the large intestines of excess mu- cus, feces, toxic and putrefying matter. Colon irrigations are — Splenic flexure. Hepatic flexure--- Ascending colon — Caecum - Pelvic colon - Pelvis - ■ Iliac colon. Rectum. Fig. 126.—Semi-diagrammatic View of the Large Intestine; the Figures Give in Hours the Average Time After Taking a Meal That Its Debris Reaches the Various Parts. (Hertz.) This diagram shows the transverse colon in a higher position than it occupies when the man is erect, and rather higher than the average even in the hori- zontal position. (From Halliburton's "Handbook of Physiology," Blakiston and Son, Publishers.) particularly valuable after operations on the alimentary tract or on the gall ducts, which interfere with the normal flow of the antiseptic bile into the intestines, resulting in the accumula- tion of toxins. They also relieve or prevent persistent vomiting which is often due to the accumulation of toxins in the body. Vomiting is very serious in all operations on the alimentary tract, gall bladder or ducts. 522 THE PRINCIPLES AND PRACTICE OF NURSING (b) To stimulate peristalsis and relieve flatulence. (c) To supply heat as a stimulant in shock or collapse. (d) To supply fluid to the body in order to increase the volume of blood, raise the blood-pressure and stimulate the heart; to relieve thirst; to supply fluid lost by vomiting, diarrhea, or hemorrhage; to dilute toxins in the body; to stimulate and flush the kidneys and relieve suppression. 2. In constipation. 3. In obstruction; the pressure must be low; the solution must be given slowly, the flow being constant, not jerky. 4. In dysentery, to cleanse from mucus and pus, and to dilute the toxins. 5. In inflammatory diseases of the lining of the large intes- tines, to supply local remedies such as tannic acid, boric acid, etc. 6. In inflammation of the kidneys and pelvic viscera.—A hot colon irrigation brings heat very close to the above organs. The heat directly stimulates the kidneys and relieves pain, congestion and suppression, and also relieves inflammation and pain in the pelvic viscera. The heat also stimulates the portal circulation, the liver and flow of bile. 7. In colic—hepatic, biliary, renal, or intestinal—to relax the muscles and relieve pain. 8. In toxemia and uremic poisoning, to dilute and help elimi- nate the poisons. 9. In poisoning from bichlorid of mercury, etc., in order to dilute and remove the poison from the intestines and body, to stimulate and flush the kidneys, and to prevent its destructive effect upon them and the resulting danger of acute nephritis and suppression, which might prove fatal. The Important Factors to Consider in Giving the Treatment in order to Get the best Results.—1. The articles required for the treatment will depend somewhat upon the method. (a) For the patient and bed.—A blanket will be necessary to cover the patient; a towel and Kelly pad will be required to protect the bed and direct the return flow of the solution into the receptacle on the floor. (b) For the treatment will be required an irrigating pole, irri- gating can with tubing, clamp and connecting tip attached, a covered basin with two rectal tubes of suitable size, one larger than the other, vaselin for lubrication, a pail for the return, a large pitcher (2 gallon) with the solution and a basin of soap and water, sponges and towel for cleansing and drying the patient. 2. The solution used depends upon the purpose. It may be: (a) Normal saline is usually used for cleansing. It removes the mucus, etc., and prevents loss of vital salts from the intes- tinal wall, and the absorption of water by osmosis, making the tissues boggy (Hare). Medications may be added to the solu- tion, if desired. (b) Plain water is used when the treatment is given to relieve TREATMENT FOLLOWING AN OPERATION 523 thirst or to stimulate the kidneys or to supply fluid for any reason. Salts, whether given in the diet or by rectal injections, must be eliminated by the kidneys, if not needed by the tissues to maintain osmotic pressure. This will mean extra work for the kidneys and to an inflamed kidney also salts are very irri- tating. Again if the kidneys are diseased they will not eliminate salts from the body so that they remain in the tissues. The tissue cells cannot tolerate salts in their crystalline form so they draw water from the blood (osmosis) to dilute and render the salts less irritating, thus resulting in edema. When the kidneys are diseased, therefore, the patient is allowed only a "salt-free" diet and plain water rectal injections are given in order to give the kidneys less work to do, to dilute excess salts and other waste products in the body and render them less irritating to the kidneys. (c) Potassium acetate (3 i to a pint) is frequently added for its diuretic effect. 3. The temperature of the solution is usually from 116 to 120° F., heat being one of the most valuable means of relieving pain, inflammation and congestion, and of stimulating the functions not only of the colon but of all those organs with which the colon is in contact, and of the body in general through its effect on the circulation. 4. The amount of solution used is usually from two to three gallons. When given for cleansing purposes the amount is deter- mined by the result as the treatment is continued until the return is clear. 5. The rectal tubes used and the way in which they are inserted also depend upon the purpose. When used for cleansing pur- poses, the inlet tube should be smaller than the outlet tube (a catheter may be used) in order to allow for the return not only of the fluid but of the feces, flatus, and mucus, etc. The inlet tube should be inserted about 6 inches while the outlet tube is inserted about 3 or 3% inches. Each tube should be marked with a narrow strip of adhesive plaster indicating when the tube has been inserted the desired distance and whether meant for the inlet or outlet of fluid. When inserted the adhesive marks on the tubes are opposite and just without the anus. If the injec- tion is given to supply fluid, in order to have some of the fluid retained, the tubes should be about the same, or the outlet tube should be a little smaller than the inlet tube. For the comfort of the patient medium sized tubes only should be used. Sometimes one rectal tube only is used which is connected to a T-shaped glass connecting tube. One arm of the glass con- necting tube is attached to the inflow tubing which is attached to the irrigating can, the other arm, to the outflow tubing. Both the inflow and outflow tubing must then be provided with a clamp. A graduated glass irrigator should be used so that the amount of fluid entering the intestines may be estimated. Position of the Patient.—Some prefer to give the treatment 524 THE PRINCIPLES AND PRACTICE OF NURSING with the patient drawn to the side of the bed, in the left Sims' position, that is, on her left side with the knees flexed, the right slightly more than the left. In this position the fluid is carried by gravity into the sigmoid and descending colon and by anti- peristalsis may be carried to the ileo-cecal valve. Others prefer the right Sims' position. When in this position, the solution is carried by gravity along the sigmoid and de- scending colon, and down the transverse colon to gradually col- lect in the ascending colon and cecum. Care should be taken not to use more water than is necessary and not to overdistend the bowel. In obstinate intestinal obstruction, when irrigations with the patient in the above positions fail to bring about evacuations or relieve the condition, sometimes the knee-chest position is used (See knee-chest position, p. 513). The advantages of this posi- tion, in irrigating the colon, are that it allows the solution to run in easily by gravity so that it reaches all parts of the colon and removes threadworms, excess mucus or accumulated feces from the cecum and entire colon. The disadvantages are that it is very trying and apt to be exhausting, particularly to a patient already weakened by disease. In all cases the patient must be carefully supported by an assistant and the treatment given as gently and skilfully as possible. If necessary, the treatment may be given with the patient lying on her back with the hips elevated. Whatever position is used must be made as comfortable as possible for the patient as the treatment lasts for a considerable time. See that the patient is properly protected from chilling and from unnecessary exposure, that the bedclothes are neatly turned back, and the towel and Kelly pad placed under the patient to protect the bed, and so that the end of the pad hangs in a pail on the floor. The towel is placed under, not over the Kelly pad, so that when the wet pad is removed, the patient will rest on a warm, dry towel. This prevents the bed from being wet and the towel serves to dry the patient. The Kelly pad should be warmed before placing it under the patient. Method of Procedure.—Hang the irrigating can about 3 feet above the bed; attach the tubing, clamp and inlet tube; pour the solution into the can; allow the solution to run through the tubing to expel the air and warm the tubing; then clamp it. Lubricate both the tubes and insert them both at the same time. This is easier and causes much less distress to the patient; when one is inserted the sphincter of the anus closes tightly on it, mak- ing it very difficult to insert the second tube. Sometimes the insertion of the two tubes together is made more easily if a hole is made in the side of the outflow tube into which the end of the inflow tube is inserted. They are thus inserted as one tube. After they are inserted to the mark on the inflow tube, both tubes are then adjusted so that each is inserted the desired distance as indicated by the markers on the tubes. The end of TREATMENT FOLLOWING AN OPERATION 525 the outflow tube should be about a foot below the level of the patient in order to avoid too great suction. This would be apt to draw the mucous membrane into the holes in the outlet tube, and not only interfere with the return, but also injure the delicate membrane. If the outflow colon tube is not long enough to per- mit this it should be attached by a connecting tip to another piece of tubing. Also if this tubing does not extend to within about a foot of the pail on the floor when considerable gas is expelled, it will scatter the fluid and fecal matter, soiling the bed, etc. When the distance from the pail is too great, the noise and splashing are also objectionable. Inject the solution slowly so as not to excite the bowel to contraction. This allows the desired amount to be given and secures the desired effect—thorough cleansing or retention, etc. Very little force should be used. If the patient complains of abdominal pain, clamp the inlet tube for a few seconds and note whether flatus is expelled or not —pain is frequently due to the contraction of the muscles in the effort to expel the gas. If the pain is continuous, stop the treat- ment. If properly given there is usually no pain. If there is difficulty in obtaining the return, move the outlet tube up or down. It may be necessary to remove and cleanse it. Stop the treatment if the patient shows signs of exhaustion. When the desired effect has been attained remove the tubes gently; cleanse the patient; remove the Kelly pad and dry the parts. If the parts are irritated a soothing ointment should be applied. Chart the amount of solution used, the amount retained and the results—whether there was much fecal matter, odor, flatus or mucus, etc., in the return and whether the treatment caused pain or not. A PROCTOCLYSIS, RECTAL INFUSION OR SEEPAGE The word proctoclysis comes from two Greek words; procto comes from proktos which means anus or rectum; clysis from the Greek klysis, a washing out of stagnant or waste materials in any cavity. The treatment is commonly called the "Murphy drip" after the noted surgeon who first used and described it. The purposes of the treatment are much the same as in the enteroclysis, when that treatment is given in such a way that some of the solution will be absorbed. The proctoclysis, or Murphy drip method, is a form of enteroclysis in which the solu- tion is introduced into the rectum drop by drop for the purpose of supplying the body with fluid and at the same time freeing the intestines of gases and toxic products, etc. The treatment may be continuous and all the fluid is intended to be absorbed —sometimes a pint an hour may be absorbed. It is given to supply fluid in postoperative cases, in suppres- sion, in toxemia, and in septic cases, for the purposes mentioned in an enteroclysis. 526 THE PRINCIPLES AND PRACTICE OF NURSING In septic peritonitis it relieves thirst and dilutes the toxins absorbed from the infected peritoneum. Dr. Murphy also be- lieved that it reversed the flow of lymph in the lymphatics of the peritoneum, that is, that, instead of the toxins being absorbed by the lymph vessels to be carried to the blood stream causing a general toxemia, the lymphatics poured out their lymph into the peritoneal cavity, thus diluting the toxins, and irrigating and flushing out this cavity. In hypertension and high blood pressure, a solution containing potassium acetate is given to relax the blood vessels and to in- crease the elimination of fluid, thus lowering the tension and blood pressure. The Procedure.—The important factors to consider in giving the treatment are as follows: The Solution.—Plain water is most frequently used. Water containing potassium acetate, one dram to a pint, is frequently used in hypertension to lower the tension and blood pressure. Potassium acetate is a diuretic. Potassium is also a muscle poisoner, that is, it relaxes the muscles of the blood vessels (and other muscles) and so lowers the tension and blood pressure. The effect of potassium is neutralized by sodium chlorid or com- mon table salt. Nature recognizes this so that when we eat food, such as potatoes, rich in potassium, we, guided by our sense of taste, instinctively demand the use of salt. A hypotonic (0.5 per cent.) salt solution, that is, one contain- ing a lower percentage of salt than the blood or tissues, is some- times used. A fluid containing a higher percentage of salt (hyper- tonic) than the blood or tissues would cause fluid to be withdrawn from the tissues instead of being absorbed. A salt solution is more cleansing and is often less irritating to the lining of the intestines than plain water. A glucose solution (5 to 15 per cent.) is frequently used for its nutritive value when sufficient fluid and nourishment cannot be given by mouth as in some postoperative conditions. It pre- vents the patient from using his own body tissues with the re- sulting danger of the incomplete oxidation of fats and acidosis. The temperature of the solution should be 118° to 120°. The best method of maintaining the proper temperature is by means of the apparatus shown in Figure 127. The various devices for keeping the water hot—hot-water bags, flannel, asbestos, etc., around the can or tubing, electric-light bulb in the can, etc.— have proved of little effect unless the water is heated shortly before reaching the rectum. Water flowing drop by drop through the rubber tube (even though kept warm) will be cooled when leaving the catheter. The solution enters through a catheter inserted into the rec- tum, a catheter being used because it is small, therefore less apt to irritate and excite the bowel to contraction. All air should be expelled before inserting it. It should be well lubricated but not with glycerin as glycerin stimulates peristalsis. TREATMENT FOLLOWING AN OPERATION 527 Care should be taken to see that the catheter is properly in- serted, that the solution is being absorbed, that there is no leak- age into the bed, and that no pressure on the soft catheter is obstructing the flow. The rectum may become irritated and intolerant of the tube, so that it may be necessary to stop the Fig. 127.—Proctoclysis Apparatus, Consisting of Fountain Syringe, Large Rubber Tube, and Vaginal Hard-rubber or Glass Tip. (From Hare's "Practical Therapeutics," Lea and Febiger, Publishers.) treatment to give the parts a rest. It may be resumed later. It is wise to have the bed protected. It is also sometimes neces- sary to disconnect, to remove the catheter to squeeze out air from the tube to allow the solution to run. The regulation of the flow is extremely important. The rate of the flow should be about twenty drops per minute (thirty 528 THE PRINCIPLES AND PRACTICE OF NURSING being the maximum). This may be regulated by gravity, that is, arranging the irrigator at a height just sufficient to obtain a pressure which will overcome the opposing pressure in the intestines (due to gases, fluid, fecal matter, etc.) and allow the solution to enter drop by drop and be retained and ab- sorbed. This is usually a very difficult pro- cedure requiring constant readjustment. The use of the apparatus shown in Figure 127 overcomes the difficulty both in regulating the flow and in keeping the solution hot; also in estimating the amount absorbed and in mak- ing provision for cleansing the colon by allow- ing the water to flush back and forth remov- ing the gases, etc., which would otherwise pre- vent the absorption of the solution. The clamp is used to regulate the flow and by means of the dropper the rate may be ob- served and counted. The tubing for the return of flatus, etc., may drain into another container, if desired; otherwise the solution in the irrigator should be changed frequently. The duration of the treatment may be for days, absorption sometimes taking place at the rate of sixteen pints in twenty-four hours. The position of the patient may become ex- ceedingly trying and, when possible, should be changed frequently. She is not likely either to retain or absorb the solution if in a strained uncomfortable position. She may lie on her side, on her back in the semi-recumbent po- sition, or may be supported in Fowler's posi- tion. In charting the treatment, note carefully the amount of fluid absorbed and the char- acter and amount of fecal matter and flatus, etc., in the return. Fig. 128. — Coup- ling of Glass to be Put in Rub- ber Tubing so as to Count the Drop-rate, with Compressor to Regulate Flow (Meinecke). (From Hare's "Practical Thera- peutics," Lea and Febiger, Publish- ers.) RECTAL FEEDING OR THE NUTRI- TIVE ENEMA Purpose of the Treatment.—The nutrient enema or rectal feeding is the injection into the rectum of concentrated, partially digested liquid food in the hope that part of it at least will be ab- sorbed and supply the body with nourishment. There is little, if any digestion in the large intestines, but considerable absorp- tion of water and of such substances capable of passing through the mucous lining. It is said that only about one-fourth of the body needs can be supplied by rectal feeding but this is suffi- TREATMENT FOLLOWING AN OPERATION 529 cient to save the body tissues and to tide over an emergency. This method of feeding can be used for a limited time only, as the intestines soon become irritated and intolerant, especially if the same method is used repeatedly. It may, however, be re- sumed after a rest. Hare states that "Comparatively recent in- vestigations have proved conclusively that so-called nutrient enemeta aid very little in maintaining nutrition, most of the benefit being due to the fact that the fluid part of the injection is absorbed but the solids remain in the bowel." Conditions in which Rectal Feedings are Used.—Rectal feeding is resorted to when for any reason food cannot be given to the patient by mouth or when it is necessary to spare the stomach. It is used in such conditions as (1) emaciation and depletion in order to supplement feeding by mouth; (2) persis- tent vomiting; (3) operations on the mouth or jaw; (4) obstruc- tion or stricture of the esophagus or at the pylorus (due to stric- ture or cancer, etc.); (5) diseases of the stomach and operative conditions such as gastric ulcer; (6) diseases in which the patients are unconscious, irrational or comatose. The ingredients of a nutrient enema vary, but they should always be as absorbable as possible and as only small amounts may be given the food should be concentrated. The foods most likely to be absorbed are peptonized milk, dextrose, sugar of milk, concentrated protein such as liquid peptonoids, beef pep- tones, either a whole egg or the white of egg, which is albumin, therefore absorbable, beef-juice and whisky or brandy. Alcohol, in ordinary amounts, is one of the best foods for the production of energy. It is readily oxidized and supplies energy for rest or work. It does not build tissue but, for a certain time, will yield the energy that fat would yield and so spares or prevents draw- ing upon the protein and body tissues for energy. If continued beyond the energy requirements of the body its action on the tissues is destructive. Salt added to the egg aids its absorption. Dextrose has a high nutritive value and as it passes easily through membranes is readily absorbed, but it is also irritating and may prevent absorption by exciting peristalsis. The retention, possible digestion, and absorption of the nutri- ent enema depend upon the following factors: 1. Antiperistalsis may carry the food to the colon and cecum. 2. When given to supplement feedings by mouth, digestive juices from the small intestines may be carried along with the food to the cecum and continue to digest any food present in the cecum just as digestion by the saliva may continue in the stomach until neutralized by the hydrochloric acid. 3. Bacteria, also, always present in the intestines, may act as enzymes by splitting up the food and thereby aiding digestion. 4. Experiments have shown that there is considerable absorp- tion of fluid in the cecum and ascending colon, the contents of the cecum consisting of 90 per cent, water, that of the transverse colon being only 75 per cent, water. 530 THE PRINCIPLES AND PRACTICE OF NURSING To aid its retention and absorption, the important factors to remember in order to obtain the best results are: 1. The purpose of the enema and importance to the patient. The nutrient enema may be the only means of feeding the patient for weeks at a time, so that as his life may depend upon it, the utmost patience and skill should be used to secure the best pos- sible results. 2. The condition, both mental and physical, of the patient must be such as to aid in the retention and absorption of the nourish- ment. He must be free from all causes of mental excitement, and of physical discomforts or unrest. 3. The condition of the bowel, also, must be clean and healthy, therefore a cleansing enema should always be given once in twenty-four hours to free the intestine from all residue which, if not absorbed, will be very irritating, causing diarrhea and keep- ing up a continual unrest preventing absorption. An injection of normal saline is usually given once in twenty-four hours. The saline removes mucus and stimulates the circulation, therefore it is cleansing and aids absorption. A schedule frequently fol- lowed for twenty-four hours is: 4 A. M. A nutrient enema 8 A. M. 12 noon A S. S. 4 P. M. A nutrient " 8 P. M. 12 M. A normal saline enema, or the nutrient enema may be given every four hours, the simple enema and the saline enema being given at 10 A. M. and 10 P. M., but frequent passage of the tube is irritating, therefore interferes with retention. 4. The foods used must be predigested, as there are no diges- tive juices secreted in the large intestine. 5. Small amounts only (4 to 8 ounces) should be given every four to six hours. 6. The injection must be given very slowly and the temperature must be body heat, neither hot nor cold, so as not to excite peris- talsis. For the same reason it must be given through a catheter, well lubricated, but not with glycerin, as glycerin stimulates peristalsis. It should be injected as high as possible so that antiperistalsis can more easily carry it to the part of the colon and cecum where absorption is greatest. To quiet the intestine and prevent evacuation, the injection may be preceded by an opium suppository or tincture of opium may be added to the enema. 7. After the injection the patient should be kept as quiet and comfortable as possible. She must be encouraged to retain the nourishment and must not be worried or disturbed in any way. It frequently helps to have the pelvis higher than the body, to apply pressure against the anus until the desire to expel the TREATMENT FOLLOWING AN OPERATION 531 enema is passed, or to leave the catheter inserted, with a knot tied in it to prevent the expulsion of the enema. The bedpan should not be allowed the patient for some time after the injection. When a nutrient enema is given to a patient suffering from hemorrhoids particular care should be taken. Sometimes it is necessary to paint the parts with 2 per cent, cocain and to apply a soothing ointment to the parts in the intervals between the treatments. When charting the enema, note the time, the ingredients used and whether it was retained or not. CATHETERIZATION OF THE BLADDER The simpler nursing measures used to relieve retention of urine following an operation have already been discussed in Chapter XII. When Nature and all other methods fail to relieve this condi- tion, catheterization must be resorted to. This treatment con- sists in the withdrawal of urine by means of a catheter introduced through the urethra into the bladder. The Anatomical and Physiological Factors to be Considered are as follows.—The blad- der is a highly elastic musculo - membranous sac situated, normally, low in the pelvic cavity behind the symphysis pubis. When distended, it extends above the symphysis pubis and may easily be seen or felt. The function of the bladder is to serve as a reservoir for urine which is secreted con- stantly by the kidneys and passed drop by- drop through the ureters into the bladder from where it is expelled periodically, usually when it has accumulated to about eight or ten ounces. The normal capacity of the bladder is one 532 THE PRINCIPLES AND PRACTICE.OF NURSING pint (500 c.c.) but it may reach to 1000 c.c. under normal condi- tions and with retention may reach to 3000 or even 4000 c.c. Retention of urine, if chronic, predisposes to infection. It may also interfere with the work of the kidneys, for the ureters, and therefore the kidneys, cannot empty when the walls of the blad- der are distended. Woolsey states that "the oblique passage of the ureter through the bladder walls downward and inward for one-half to three-quarters inches . . . acts as a valve, prevent- ing reflux into the ureter, so that the fuller the bladder, the more tightly is the ureter mouth closed." Anything which interferes with the free flushing of the kidneys, predisposes them to infec- tion, otherwise prevented by the constant flushing and removal of bacteria and waste products. The bladder is controlled by the central nervous system. It is supplied by branches of the same nerves which supply the other pelvic organs, rectum and anus, so its function may be affected by operations upon them. The contraction of the diaphragm in inspiration causes pres- sure on the abdominal organs and aids in the expulsion of urine. The urethra is the passageway from the bladder to the exterior. (See Figures 50 and 51.) It is situated in the female, in the anterior wall of the vagina with which it is closely associated, so that any packing, growth or other obstruction in the vagina will cause pressure on the urethra and interfere with voiding or the insertion of a catheter. The muscular walls of the urethra are normally in contact but the urethra is quite distensible. Nervousness, exposure and chilling, etc., may cause contraction of the muscular walls making it impossible to pass a catheter. The direction of the urethra, when the patient is in the dorsal, recumbent position, is upward and backward. The length of the female urethra is about 1% inches. The meatus of the female urethra is situated normally between the labia minora of the external genitals, in the center of the papilla just above the opening of the vagina and about one inch behind the clitoris. It may be hard to find in the following con- ditions: (1) in children; (2) when the surrounding parts are red and swollen; (3) after an operation such as a perineorrhaphy, sometimes stitches have accidentally been made through the meatus; (4) when the vagina is tightly packed, crowding the urethra and meatus; and (5) in certain malformations, as for instance when the urethral meatus is in the vagina. The external genitals are never absolutely clean or free from germs owing to the discharges from the vagina and rectum. Conditions in which Catheterization is Resorted to.—1. Re- tention of urine.—This may be due to a temporary paralysis fol- lowing an anesthesia, to dulled senses following the use of drugs such as alcohol and morphin, etc., to paralysis, to shock, to operations on the pelvic organs or on the rectum or anus which are supplied by the same nerves, to loss of tone in the muscles of the bladder or to a nervous contraction of the urethra. TREATMENT FOLLOWING AN OPERATION 533 2. Retention with overflow.—In this condition there is volun- tary or involuntary micturition, in small, frequent amounts, which does not relieve the bladder. The bladder is distended and can easily be seen or felt and the patient is in constant dis- tress, obtaining no relief from voiding. 3. Involuntary micturition.—This may occur when the patient is in a stupor or coma or may result from injuries to the spine or after an operation such as a prostatectomy. It sometimes becomes necessary to catheterize patients having involuntary micturition in order to prevent irritation from the urine and breaking down of the tissues or bedsores. Highly acid urine is very irritating. Urine which has decomposed in the bladder or which has been allowed to remain on the skin until decomposed is also very irritating. The irritation and odor of decomposed urine are due to the presence of ammonia which results from the decomposition of urea, the chief ash re- sulting from the metabolism of amino acids (protein). In the metabolism of amino acids in the body, ammonium products are formed and to prevent their accumulation, these are changed by the liver into urea, a non-irritating substance easily eliminated by the kidneys. Urea is easily decomposed by bacteria. To prevent bedsores the parts should be absolutely clean and dry, washed with boric acid to neutralize the decomposed alka- line products, rubbed frequently with alcohol and the skin oiled to prevent the urine from coming in contact with the skin. 4. Catheterization as an aid to diagnosis. (a) It is sometimes difficult to tell whether the small amount of urine voided is due to failure of the bladder to expel the urine (retention), or to failure of the kidneys to secrete urine (sup- pression). This is a much more serious condition and if not re- lieved will finally cause edema, coma, convulsions and death. The patient is catheterized to find out if there is any urine left in the bladder. (b) Again, when it is necessary to find out whether disease of the urinary tract is due to bacteria, or to find out if bacteria are being passed in the urine from disease of some other part of the body (as in typhoid) it is necessary to obtain a sterile specimen of urine, and this can only be done by catheterization. Urine although free from bacteria when voided, will always contain bacteria after it has passed over the external genitals. 5. Catheterization to prevent infection of a wound.—It is a rule, with some surgeons, to have a patient catheterized every eight to twelve hours following an operation on the perineum or external genitals, etc., to keep the stitches dry and the wound free from infection until it is healed sufficiently to be no longer in danger. Other surgeons feel that, if the parts are kept clean, particularly after the use of the bedpan, the urine will do little harm, whereas frequent catheterization may do considerable harm. Dangers Involved in Catheterization.—Even when this treat- 534 THE PRINCIPLES AND PRACTICE OF NURSING ment is given with the greatest care, aseptic precautions, and skill, there is considerable risk of the patient developing cystitis as a result. This is particularly true when the treatment must be repeated over a period of days or weeks, or when the patient's general weakened condition predisposes to infection. The dan- ger is also great when in a general septic condition a slight irri- tation of the lining only is necessary to cause a local infection or when an infection of the external genitals exists. It is therefore resorted to only when absolutely necessary and, as the dangers are more fully recognized and appreciated, it is used much less than formerly. Many surgeons prefer to run the risk of infec- tion of a perineal wound, etc., by allowing the urine to pass over it, rather than run the risk of the patient developing cystitis from catheterization. Following an operation the patient will be allowed to go without voiding, unless in actual discomfort or pain, for a much longer period than formerly, even often for eighteen hours. Again, the weakened condition of the bladder, which prevents it from emptying itself in the normal way, the interference with its circulation and nervous mechanism which exists, lowers its resistance and predisposes it to irritation and infection. Also, when urine is retained in the bladder it decomposes, liberating ammonia products which are very irritating to all tissues and predisposes to infection. The bladder is warm, dark and moist and so is an ideal place for bacteria to develop if once lodged there, especially when the free passage of urine is interfered with. While cystitis is not a fatal disease, it causes a great deal of pain, discomfort and inconvenience, and, once developed, is ex- tremely difficult, if not impossible, to cure entirely. The blad- der becomes a weak spot so that cold, exposure or a rundown condition, etc., may cause a chronic condition to flare up and become acute. Cystitis developed in the hospital as a result of catheterization, not only causes great discomfort to the patient, but may involve the hospital in a very costly lawsuit. It may result from (1) unsterile instruments, utensils or hands; (2) bacteria carried in from the meatus or surrounding parts; (3) traumatic irritation of the lining of the urethra and bladder from the mere passage of the catheter. Before catheterizing a patient, or even reporting that she is unable to void, every nursing measure should be tried to cause the bladder to empty itself in a normal way. One of the meas- ures of a good nurse is her ability to use her science and art to restore her patient to normal by nursing measures which render drugs and treatments (which may possibly do harm) unnecessary. The Procedure.—The principles to be observed in catheteriza- tion are: 1. The prevention of infection by thorough cleansing of the part, by surrounding the part with sterile towels, using sterile instruments and utensils, and allowing nothing unsterile to come in contact with the meatus. Sterile towels are not essential. The TREATMENT FOLLOWING AN OPERATION 535 most strict asepsis may be observed without them. Some of the very best hospitals do not use them believing that, as they are not always available outside the hospital, nurses should be trained in asepsis without relying upon them where they can, with safety, be dispensed with. In all treatments, simplicity makes for ef- ficiency, and the more simple the technique the less chance for error or for infection. 2. The avoidance of injury by using the proper catheters and the proper method of inserting them. 3. The protection of the patient from exposure and chilling, etc. The articles necessary for catheterizing a female patient are two or three sterile catheters and sterile sponges boiled for five minutes (and brought to the bedside in the receptacle in which boiled), sterile towels for draping (?), sterile basin for receiving the urine, a basin for the discarded sponges and catheter, a basin of hot boric solution for cleansing the parts; the water in which the catheters, etc., are boiled may be poured off and boric acid added. Sterile gloves are sometimes used and sometimes a basin of hot antiseptic solution is brought to the bedside for soaking the hands as a last precaution. Some hospitals use sterile forceps for handling the sponges and catheters and in some, where gloves are not worn, gauze sponges are wrapped around the fingers of the nurse to protect her from infection from a possible infectious vaginal discharge. All the articles may be brought to the bed- side on a tray. The sterile articles may be enclosed in a sterile towel. The catheters used may be made of glass, soft rubber or silver. Glass catheters are about six inches long, with a bent, rounded tip and holes in the side. The advantage of glass is that it is easily kept clean and sterilized. The disadvantage of glass is that it is easily broken or cracked in boiling and may break when in the bladder. This would be a very serious accident. Also, there are conditions in which it would be unsafe to use a glass catheter because of the danger of breakage. They are used only for women. A rubber catheter must always be used (1) for all restless, nervous, delirious or irrational patients; (2) for children and irre- sponsible patients; (3) for pregnant women; (4) for conditions in which there is a stricture or obstruction in the urethra to the passage of the catheter; (5) following operations on the vagina or perineum; (6) when the vagina is tightly packed making the passage of the catheter difficult and breakage liable if glass were used. When a rubber catheter is used some authorities consider it necessary to lubricate it with a sterile lubricant, while others consider this unnecessary and that it is safer to use the catheter lubricated only by the solution in which it stands. Preparation of the Patient.—If the patient is conscious and rational explain the necessity for the treatment and the need for her cooperation. Try to relieve any nervous dread of exposure 536 THE PRINCIPLES AND PRACTICE OF NURSING or discomfort. She should be thoroughly relaxed and remain per- fectly still. One of the most essential things in the treatment is a good light. While very little exposure is necessary, the nurse should see exactly what she is doing and be free to give her entire attention to the treatment. The position of the patient is important. She should lie on her back near the right side of the bed, with her thighs and knees flexed and limbs well separated and relaxed. A blanket should be placed across the chest as it is most important that the patient should not become chilled. Cold causes muscles to contract so that the patient is rigid and also predisposes to cystitis. After the patient's gown, the upper bedclothes, the sterile draping and the utensils (which must be in a convenient position) are ar- ranged satisfactorily and everything is in readiness to begin the treatment, the nurse "scrubs up" after which she must touch nothing unsterile (at least with her right hand). Before leaving the patient to "scrub up" a sterile pad or folded towel may be placed over the vulva to avoid exposure. Method of Procedure.—The nurse should stand on the pa- tient's right and before touching the catheter she should, with thumb and index finger of her left hand, separate the labia gently but sufficiently to clearly expose the meatus. Then with moistened sterile sponges (in her right hand) she should thor- oughly cleanse the parts, wiping gently but firmly from above downward, using each sponge only once and handling it so that her fingers touch nothing but the sterile surface of the sponge. The last sponge is usually left in the vaginal orifice to avoid con- tact with any discharge which might be present. When this is done care should be taken that this sponge is merely placed in the orifice and not packed in the vagina as this would cause pres- sure on the urethra and interfere with the passage of the catheter. Then, without removing the fingers of her left hand from the labia, with her right the nurse introduces the catheter directly into the urethral meatus without allowing it to touch anything else. The nurse also, though her hands are "clean" never touches the end of the catheter to be inserted. Before inserting a glass catheter always examine it carefully for cracks. When inserting a glass (or silver) catheter intro- duce it with the curved tip pointing upward and direct it upward and backward so as to follow the curve of the urethra. The soft rubber catheter easily follows the curve of the urethra. Never attempt to introduce the catheter unless the meatus is plainly in view. If stitches or packing prevent this, they will have to be removed by the doctor. Never use force when insert- ing the catheter, but insert it gently. The muscular walls of the urethra may be contracted due to nervousness, which will pass away, or the patient may voluntarily contract the muscles if she objects to the treatment. Ask her to take a deep breath and to breathe deeply. This takes her mind from the procedure and, also, as it depresses the diaphragm, the abdominal and pelvic TREATMENT FOLLOWING AN OPERATION 537 muscles are relaxed, and the depressed diaphragm exerts pres- sure on the bladder, making the introduction of the catheter and the flow of urine less difficult. The catheter is inserted until the urine begins to flow and no further. As the urine flows, note whether it is clear or cloudy, whether there are signs of blood or pus, and whether such abnor- malities appear at the beginning or end, or throughout the flow. If a sterile specimen is desired, the urine should be received in a sterile test tube or bottle, covered or plugged with sterile non- absorbent cotton, and tagged carefully with the name of the ward, the patient, the date, diagnosis of the case, the kind of specimen, and what it is to be examined for. It should be sent immediately to the laboratory for examination. Sometimes the first or the last urine voided is required, otherwise about six ounces of the mixed urine. When the urine stops flowing, withdraw the catheter slightly so that the end in the bladder will remain in the urine as it reaches a lower level, and wait a moment to see if more urine will flow. If no more comes, then withdraw the catheter (plac- ing a finger over the open end to avoid losing this last specimen which may be desired) hold it over the basin, and, as the finger is removed, the pressure of the air will force the urine out. Place the catheter in the separate basin with the discarded sponges, etc. Before removing the fingers from the labia, cleanse and dry the parts as before. The treatment may be continued until all the urine is with- drawn or until it stops flowing. The theory that the walls of the bladder if distended may collapse, if the urine is all removed, is (in the belief of most people) an exploded one, as the walls are muscle and highly elastic, the urine is withdrawn slowly and the elastic walls contract as it is emptied. The patient should experience no discomfort during, and usually feels great relief following the treatment. Rearrange the bedclothes to the comfort of the patient. Clear away the utensils, etc. Charting.—Record the treatment, the time, whether it occa- sioned any discomfort or pain, the amount and character of the urine withdrawn—the color and odor, whether clear or cloudy and whether a sediment appeared on cooling. CATHETERIZATION OF A MALE PATIENT Male patients are catheterized by the doctor. Pupil nurses are not taught to pass the catheter on a male patient and graduate nurses are only required to do so in most exceptional cases. Nurses are, however, responsible for preparing the articles nec- essary for this procedure. The articles required will be a sterile sheet, sterile lubricant for the catheters, sterile gauze wipes or sponges for cleansing, a basin containing boric acid solution, 2 per cent., a pair of sterile 538 THE PRINCIPLES AND PRACTICE OF NURSING dressing forceps, a sterile receptacle containing several sterile catheters of different sizes, the most commonly called for being number ten, fourteen and eighteen, French soft rubber catheters. A receptacle for the discarded wipes and catheters will also be required. Rubber catheters are sterilized by boiling for three minutes. Too long boiling softens and roughens the catheters so that they become unfit for use. Method of Procedure.—If, in an emergency, a nurse is re- quired to catheterize a male patient, she should take the same precautions to prevent infection and exposure as when catheter- izing a female patient. The patient may be suitably draped and the treatment performed with very little exposure. The catheter is lubricated with a sterile lubricant. Before inserting the catheter the penis is cleansed; the foreskin is gently pushed back and the glans and meatus are cleansed with the boric acid solution in order to remove any secretions which may be present. The penis is held at an angle of about 60 degrees and the catheter is gently inserted. Frequently some resistance to the passage of the tube is met with, due to the contraction of muscles. When this occurs wait a moment and the catheter can then be gently inserted further. Force must never be used in passing a catheter as great and permanent harm may be done in this way. If the resistance is due to the nervous contraction of the muscles it will soon pass away; if not, further attempts to pass the catheter will only do harm. After the urine is removed from the bladder the parts are cleansed and dried as before. CARE OF CATHETERS The care of catheters may differ somewhat in different hos- pitals, but the following methods have been found satisfactory. Glass catheters are used for women only. After use, they are washed with green soap and tepid water, rinsed in clear water, and boiled for ten minutes. When not in use, they may be stored in a 1 to 40 carbolic acid solution. Soft Rubber Catheters.—After use they are cleansed with green soap and tepid water, irrigating from the eye downward. They are boiled for ten minutes to sterilize. If to be kept sterile when not in use they are drained and dried in a sterile towel and put away in a dry sterile towel. These catheters are then considered clean, not sterile, and are resterilized by boiling be- fore use. It is customary in most hospitals to keep a set of sterile catheters of various sizes on the ward for emergency use. A convenient method of doing so is to place the catheters, ster- ilized by boiling after use, in a sterile glass tube, long enough to accommodate the catheters without bending. They are then sent to the operating room to be sterilized in the autoclave by steam under pressure for fifteen minutes. When not used on TREATMENT FOLLOWING AN OPERATION 539 the ward they should be sent to the operating room in the tube to be resterilized once each month. Gum Elastic Catheters.—These may be cleansed in the same way as rubber catheters and sterilized by boiling. These cathe- ters become very soft and are very easily injured and ruined when hot. If not properly treated they roughen, bend, and lose their shape so that they are unfit for use. Roughened catheters, whether of glass, rubber or gum elastic, etc., should never be used. They irritate the delicate mucous membrane of the urethra and predispose to infection. To boil gum elastic catheters they should be rolled in gauze so that they do not touch each other. The vessel in which they are boiled must be longer than the catheters so that they do not become bent. The water must be boiling and the catheters should not remain in the water longer than necessary. They should be lifted from the water in the gauze in which they are wrapped. The catheters themselves must not be touched until they are cold. Lisle Thread Catheters.—These, like gum elastic catheters, are very expensive and very easily injured. After use they are cleansed with green soap and tepid water. They may be ster- ilized by boiling for one or two minutes or by soaking in a 1:1000 solution of bichlorid of mercury for one hour, and stored away in sterile glass tubes. If not used they are resterilized at least once a month. A BLADDER IRRIGATION A bladder irrigation is used when a patient is suffering from cystitis. Cystitis is inflammation of the mucous lining of the bladder. Causes of Cystitis.—The direct cause is the presence of micro- organisms in the bladder. The organism may be the tubercle bacillus, the gonococcus, the colon bacillus, the staphylococcus pyogenes or the bacillus typhosus, etc. It may be carried to the bladder with the urine from the kidneys or the blood stream, or it may enter from the urethra or the external genitals. The predisposing causes are (1) tumors; (2) calculi and other foreign bodies; (3) urethral inflammation or obstruction; (4) injury; (5) exposure to cold; (6) atony, as in old age, resulting in retention and decomposition, or anything which interferes with the normal flow of urine; (7) paralysis as in paraplegia, etc. The urine in cystitis may have a fetid odor, due to the action of bacteria, or the odor of ammonia, due to decomposition of urine in the bladder. It may be cloudy or turbid, due to the presence of the products of inflammation, and may contain a large amount of mucus, many leucocytes, and epithelial cells, blood, pus, and calculi or gravel. The purposes of the treatment are: 1. To cleanse or remove accumulated mucus, pus and other irritating products of inflammation and decomposition. 540 THE PRINCIPLES AND PRACTICE OF NURSING 2. To relieve pain, inflammation, and congestion. Bladder Irrigations are Contraindicated in the Following Conditions: 1. In acute cystitis, until the acute stage has subsided, as the lining is so very sensitive. 2. In acute urethritis, to avoid spreading the infection to the bladder. The Procedure.—The Articles Required.—These will depend somewhat upon the technique used. In addition to those used for catheterization, the following articles will be required: a sterile pitcher containing the sterile solution ordered and cov- ered with a sterile towel, a receptacle for the return (a douche pan may be used), and a sterile glass funnel attached to the catheter to be used. Rubber catheters are always used. Sterile draping is always advisable for a bladder irrigation. The treat- ment is much more complicated and prolonged than catheteriza- tion. It is also required less frequently so that nurses may not have sufficient practice to develop the skill necessary before sterile draping can, with safety, be dispensed with. The solutions commonly used are: boric acid, 2 to 4 per cent., and sodium chlorid one dram to a quart. Sodium chlorid is stimulating; it cuts mucus and is cleansing, and it is less irritating than plain water. Other antiseptic solutions are sometimes used, such as potassium permanganate, bichlorid of mercury, formalin, argyrol, and silver nitrate. The temperature of the solution for cleansing purposes should be near that of the interior of the body (the average temperature of the blood being 102° F.), as the mucous lining of the bladder is extremely sensitive to temperatures either much above or below that of the interior of the body. The temperature should be from 104° to 106° F.; if cool or hot it will cause marked contrac- tion of the bladder wall with considerable pain. The amount of solution used varies as the treatment is con- tinued until the return is clear. Usually two or three pints are necessary. The position and preparation of the patient will be the same as for a catheterization. In this treatment it is exceedingly im- portant that you should avoid the slightest chilling of the patient, allowing as little exposure as possible. Cold is one of the predis- posing factors in cystitis and chilling may bring on an acute attack with very distressing symptoms. Therefore, see that the feet and body are kept warm by using blankets. If the treat- ment is given with the douche pan under the patient for the return, see that it is not placed under her before necessary, and see that it is well padded or protected as the treatment is rather lengthy. The douche pan should be warm. Method of Procedure.—Strict asepsis must be observed throughout. First empty the bladder by catheterization, using the rubber catheter with the funnel attached, inserting the cathe- ter with the utmost care and gentleness. Hold the funnel so that TREATMENT FOLLOWING AN OPERATION 541 it will not be contaminated by contact with an unsterile surface. A long tube is unnecessary as no force should be used. If a specimen of urine is desired or if a urine record is kept, the specimen should be received in a separate basin. The urine should be measured and the amount charted. After the bladder is emptied, the solution is poured into the funnel and allowed to run in slowly, with little force. The amount allowed to enter the bladder before siphonage varies from about 1 to 4 ounces but the usual amount is about four ounces. When the bladder is very sensitive or when much contracted, some- times it is impossible to introduce even one ounce without caus- ing distress. Again when it is desired to distend the bladder completely, one pint may be injected before siphonage in order to smooth out the lining (which is arranged in folds when the bladder is empty or contracted) so that the solution will reach and cleanse all parts. This is usually not permitted without ex- press orders from the doctor. As soon as the desired amount has been introduced and before the funnel is empty, it should be allowed to pass out immediately, allowing the bladder to empty itself normally and not pressing upon the lower abdomen to hasten its discharge. Before the bladder is quite empty, that is, before the return ceases to flow, introduce more solution so as to avoid the irritation which will result from the continued strong contraction of the bladder upon itself. This flushing of the bladder is continued until the return is clear. Finish as for a catheterization. In some hospitals, in- stead of a pitcher and funnel, a douche bag and rubber tubing, etc., are used for irrigating. A recurrent catheter is, also, some- times used so that the inflow and outflow are continuous. In charting, note the amount of urine withdrawn, the amount of solution used, and the character of the return. A BLADDER INSTILLATION In the treatment of cystitis, various antiseptic solutions—silver nitrate, argyrol, potassium permanganate, etc.—are sometimes introduced into the bladder as a local application to the mucous lining, in order to prevent the development of bacteria and de- composition of urine. The drug ordered may be introduced after the bladder has been emptied by catheterization, or a bladder irrigation may pre- cede the treatment. In any case the preparation is the same as for a bladder irrigation. In addition, a sterile measuring glass containing the drug will be necessary. Before pouring the drug into the sterile measuring glass, wipe off the rim of the bottle with alcohol and do not touch the glass with the bottle or anything else unsterile. When the patient has been catheterized or the bladder irri- gated, without removing the catheter or funnel pour the drug 542 THE PRINCIPLES AND PRACTICE OF NURSING into the funnel and allow it to flow slowly into the bladder. Finish as for a catheterization. Chart the treatment, and the amount and strength of the drug used. Note whether the instillation caused the patient any pain; if so, a weaker solution will probably be required. CHAPTER XXXII NURSING CARE OF THE PATIENT, AND TREAT- MENTS USED FOLLOWING AN OPERATION (Continued) A major operation always makes a heavy drain on a patient's vitality, but even a minor operation may result in serious conse- quences either because of the patient's condition previous to the operation, or because of complications which may come in its train. The conditions most to be feared—what the nurse watches most anxiously for—are shock, hemorrhage, infection of the wound, and complications such as cellulitis, septicemia, peri- tonitis, pneumonia, and pulmonary embolism. These conditions will be discussed in the present chapter. SHOCK All patients, probably, suffer to a greater or lesser degree from post-operative shock. It is an extremely serious condition and, if not recognized and treated immediately, may prove fatal. Some understanding of the changes occurring in the body and the various factors which tend to produce the condition of shock should help the nurse to recognize its symptoms and impress upon her the need and the means of preventing its development or of treating it promptly when present. Explanation of Shock.—Shock is a condition of depression affecting almost all the functions of the body. The degree of depression varies from a feeling of slight weakness, nausea, and dizziness to a complete failure of the vital functions. No satis- factory explanation of this condition or of just what happens in the body has as yet been made although an immense amount of experimental study has been devoted to it. Various theories are advanced. The explanation generally accepted is that, while other factors may enter, the loss of vasomotor control is the con- stant and all-important factor in the development of shock. It is believed that, as the result of profound psychic disturb- ances, or of severe mechanical injuries, especially if accompanied by pain, impulses are conveyed to the brain by afferent nerves which cause a marked depression of the vital centers. The re- sult is the loss of vasomotor control, embarrassed respirations and heart action, and a tendency to lessened heat-production with an increase in heat elimination. As the result of vasomotor 543 544 THE PRINCIPLES AND PRACTICE OF NURSING paralysis, the blood-pressure is greatly reduced, the large splanch- nic veins become dilated and engorged with blood which stag- nates there instead of flowing on to feed the heart, and to be purified in the lungs, and to feed the body tissues. As the heart receives very little blood, it can deliver only small amounts to the arteries, so that the brain with its vital centers, the heart muscle, and other tissues are starving for food and smothering for want of oxygen. The starved heart muscle loses strength, its beats become very weak so that the blood-pressure, which depends largely upon the force of the heart-beat, is still further reduced and the tissues still further depleted. The conscientious heart in order to make up for the small output at each beat, works faster and faster in order to raise the blood-pressure and keep the blood circulating to meet the demands of the tissues. The heart is usually, the last worker to give up the fight, and, if supplied with more blood, quickly revives and goes cheerfully on with its work. The starved brain and its nerve centers become more de- pressed, the respirations rapid, shallow and irregular, the pulse rapid, weak and irregular, the blood-pressure very low, and the patient quickly sinks into a condition verging on complete uncon- sciousness and total collapse. Causes of Shock.—Predisposing Causes.—Shock is much more apt to develop in the old, weak, or poorly nourished, in patients with a highly impressionable nervous system, and in those ex- hausted by either mental or physical strain or poisoned by alcohol or other drugs. Exciting Causes.—Any agent which produces a violent impres- sion on the central nervous system or any agents, such as ether or chloroform, which are highly toxic and cause marked depres- sion may produce shock. Common Causes.—1. Violent emotions such as grief or fear, both of which cause marked depression of the whole nervous system and therefore of the vital centers. 2. Extreme pain such as may precede or follow an operation or accompany severe burns, crushing injuries or laceration and mangling of the tissues by machinery. 3. Operations or injuries with prolonged ex- posure of the patient with loss of body heat. 4. Exposure or rough handling of the abdominal viscera in operating. 5. Op- erations or injuries accompanied by severe hemorrhage or injury to nerve trunks. 6. Extensive wounds in the skin. 7. Direct pressure over the heart and large blood vessels, and injuries to the larynx. Symptoms of Shock.—The following description is given by Dr. W. G. MacCallum as a typical example of shock: "A. strong and perfectly healthy young man was struck in the abdomen by the pole of a carriage drawn by a runaway horse. No recogniz- able injury was done to any of the internal organs. Neverthe- less, grave symptoms made their appearance immediately after the accident. The injured man was lying perfectly quiet, and TREATMENT FOLLOWING AN OPERATION 545 paid no attention to anything going on around him. His face was drawn and peculiarly elongated, the forehead wrinkled, and the nostrils dilated. His weary, lustreless eyes were deeply sunken in their sockets, half covered by the drooping eyelids and surrounded by broad rings. The eyes had a glassy and vacant expression. The skin and the visible mucous membrane had a marble-like pallor. Large drops of sweat hung on forehead and eyebrows. The rectal temperature was subnormal. The sensi- bility of the entire body was greatly reduced; the patient reacted slightly, and only to very painful impressions. No spontaneous movements of any sort were made by the patient. On repeated and urgent requests he showed that he could execute limited, brief movements with his extremities. When the limbs were lifted passively, then let go, they fell down like lead. The sphincters were intact. The urine obtained by catheter was scanty and concentrated, but otherwise normal. The almost im- perceptible pulse was rapid, irregular, and unequal. The' arteries were narrow and of very low tension. The patient answered slowly, reluctantly, and only after repeated urgent questioning. His voice was hoarse and weak, but well articulated. On being repeatedly questioned, the patient complained of cold, faintness, and deadness of all parts of the body. When he shut his eyes he felt nauseated and dizzy. The respirations appeared irregu- lar; long, abnormally deep, sighing inspirations interchanged with rapid and superficial ones, which were scarcely visible or audible." x To summarize:—Following an operation (or injury) the symp- toms to be watched for most closely are apathy, pallor, a pinched drawn face, cold, moist, clammy skin, extreme weakness, a rapid, weak, irregular pulse, rapid, sighing, irregular respirations and lowered blood pressure. Treatment of Shock.—Prophylactic.—The treatment before an operation is extremely important, quite as important as that following, for it may prevent shock to a large extent. The need of a good night's rest, of comfort, warmth, a cheerful, hopeful frame of mind, a body well nourished and tissues well supplied with water has already been dwelt upon in an earlier chapter. Anoci-association in the Prevention of Shock.—The belief that shock is due to afferent impulses either psychic or traumatic in origin has led to the application of anoci-association to prevent operation shock. (The word noci comes from the Latin word nocere, to injure.) Anoci-association means the exclusion of all harmful impulses, influences, or associations. Before the operation, the harmful and depressing effects of anxiety, fear, and dread of pain are prevented by numbing the brain with hypodermic injections of morphin and scopolamin. Sometimes, during the operation—for instance, in exophthalmic goitre—the field of operation is blocked off and all pathways '"Text-Book of Pathology," by Dr. W. G. MacCallum. 546 THE PRINCIPLES AND PRACTICE OF NURSING broken by injections of novocain, so that no harmful impulses reach the central nervous system from the injured tissues. Be- fore closing the wound, quinin and urea hydrochloric! are in- jected around the whole area so that for several days after the operation, no impulses reach the brain from the injured tissues. This method has been developed, and is recommended by Dr. Crile because he believes that general anesthesia does not pro- tect the brain cells from harmful stimuli from the tissues oper- ated upon, and that these play an important part in the develop- ment of shock. During an operation the patient is kept well under the anes- thetic to prevent harmful impulses reaching the brain. All bleeding, If possible, is completely checked. The operation is performed with speed and the patient returned promptly to a warm bed. In an abdominal operation exposure is avoided, the contents are handled as little and as gently as possible and are protected with hot saline pads. After the operation the patient should be placed in the recum- bent position, kept absolutely quiet and moved about as- little as possible in order to relieve the work of the struggling heart. The room should be dark and no visitors, or talking, or noise of any kind, likely to disturb the patient, allowed. Morphin is usually ordered to prevent pain, one of the common factors in the development of shock. The patient's head should be lowered by raising the foot of the bed or placing him in the Trendelenburg position in order to supply the anemic brain with blood and revive the vital cen- ters. To further increase the blood supply in the heart and brain, the extremities may be bandaged—the arms, from the fingers to the shoulder; the leg, from the toes to the hips. No tight clothing or weight of bedding should be allowed about the chest as this would further embarrass the breathing. To prevent heat elimination and to raise the body temperature, heat in the form of extra blankets, hot-water bottles, and fric- tion with a warm towel to the extremities should be applied. Friction with the warm towel stimulates the circulation, removes perspiration and dries the patient. (In treating an accident case for shock, never allow the patient to remain on the cold ground or floor even if warmly covered.) It is said that hot fluids by mouth have little effect, as they remain unabsorbed in the stomach, but that after reaction has set in they are valuable. To stimulate the heart, a mustard plaster or local heat is some- times applied over the heart. Care must be taken not to oppress the chest as pressure on the chest will increase the shock. To increase the volume of blood, to increase the force of the heart and raise the blood-pressure, direct transfusions of blood or repeated intravenous infusions of hot normal saline solution, with or without adrenalin, may be given. Various stimulants—atropin, strychnin, whisky, caffein, camphor, hot coffee (caffein), and digitalis—are extensively TREATMENT FOLLOWING AN OPERATION 547 used, but it is said that recent studies seem to contraindicate their use as they tend to stimulate consciousness or open up pathways for afferent impulses, thus intensifying shock (Hare). They are, however, valuable and are given in cases of extreme shock to ward off immediate death and revive the patient while other treatments are being prepared. When large or repeated doses of stimulants are given it is important to watch later for symptoms of cumulative poisoning. The treatments used to relieve shock are much the same as those used to relieve the effects of hemorrhage. They will, there- fore, be discussed under the treatments for hemorrhage. HEMORRHAGE As life depends upon a free supply of blood to all the vital centers in the brain, the vital organs, and all the tissues of the body, loss of blood is, perhaps, the most serious condition which may endanger the life of a patient, following an operation. The possibility of a hemorrhage should be constantly present in the mind of the nurse in charge of the patient, for his life will depend upon its prompt recognition and prompt, intelligent control. Not one drop of blood should be unnecessarily lost. Thousands of patients owe their lives to the quick recognition of the first signs of hemorrhage. The patient's life is, therefore, in the hands of the nurse. If her care is to be intelligent she should know whether the patient's previous condition makes him more liable to bleeding as in hemophilia, jaundice, or diabetes; whether the patient has lost much blood during the operation, and in whom the loss of blood is particularly serious, as in the old or very young, and in those in whom the vitality is lowered from any cause. She should know in, or after which operations bleeding is most likely to occur as in operations on the spleen, liver, pan- creas, gall bladder, kidneys, uterus, rectum, tonsils, mouth; and also in infected wounds, and in operations involving large raw surfaces. She should also know and be able to recognize the earliest symptoms and should know what to do and how to do the right thing instantly should a hemorrhage occur. Bleeding which occurs at the time of the operation or within the first twenty-four hours is called a primary hemorrhage. It may be (1) a steady oozing from capillaries which may be pro- fuse, particularly if the wound involves a large area or, (2) bleeding from small blood vessels not tied off at the time of the operation or, (3) bleeding from a large vessel due to the slipping of a ligature. At the time of the operation, owing to the depressing effect of the anesthetic on the circulation, bleeding from the capillaries may be very slight and the clotting of the blood easily controls it; bleeding from the small blood vessels may be so slight as to be overlooked by the surgeon so that they are not tied off; or, a ligature around a large vessel may be tied too near the cut edge, 548 THE PRINCIPLES AND PRACTICE OF NURSING or it may not be tied securely. As the depressing effect of the anesthetic wears off, the heart beat becomes stronger and the blood-pressure is increased so that blood clots are easily dis- placed and bleeding begins from the capillaries and small blood vessels. The increased blood-pressure may cause a ligature to slip so that bleeding may occur from a large vessel. Restless movements of the patient increase the rate and force of the heart beat and raise the blood-pressure, thus greatly increasing the danger of hemorrhage. Bleeding may be external, sudden and large or it may be exter- nal and gradual—in either case it should be recognized instantly both by the external evidence and systemic symptoms. Where the wound is closed, with no means of drainage, or when the wound is tightly packed, the bleeding will be internal; that is, into the tissues or into a body cavity. An internal hemorrhage may also be sudden and large, in which case the systemic symp- toms are very marked and unmistakable, or it may be very gradual, in which the condition may be mistaken for prolonged shock. This is a serious error as stimulants are given to relieve shock, but are avoided in hemorrhage as they, of course, would increase the amount and rapidity of the loss of blood. A hemorrhage is said to be secondary when it occurs any time after the first twenty-four hours up to the time of complete heal- ing of the wound. A secondary hemorrhage is apt to be severe as it usually occurs from a large vessel, the smaller vessels being always occluded after the first twenty-four to forty-eight hours. It is to be watched for, particularly in septic wounds where there is sloughing of the tissues, with which there may be sloughing and slipping of ligatures or erosion of the walls of the blood vessels. Signs of Hemorrhage.—The dressing should be watched for any staining with blood. If the dressing is stained, the spot should be watched to see if it increases in size. When examining a dressing for staining, always examine the binder or bandage on which the patient is lying. The outer non-absorbent covering of the dressing may prevent the binder or bandage immediately over the wound from being stained but the blood will escape from beneath the dressing and flow by gravity to the lowest point, so that the binder and bed beneath the patient may be saturated before any staining appears on the outer dressing. An internal hemorrhage is indicated by the systemic symptoms. Systemic Symptoms of Hemorrhage.—Dr. Brewer describes these symptoms as follows: "A moderate loss of blood in a vigorous, healthy individual produces no symptoms other than a feeling of slight weakness. If the amount lost is greater, there is a feeling of giddiness, dyspnea on exertion, mental confusion, and a disposition to faint. In severe cases there may be in addition thirst, air-hunger, par- tial blindness, ringing in the ears, and suspended consciousness. Accompanying these symptoms there are pallor, coldness of the TREATMENT FOLLOWING AN OPERATION 549 extremities, a moist, clammy skin, rapid sighing respiration and restlessness. The pulse is rapid, feeble, thready, irregular, and compressible; the temperature is sub-normal; there is great physical weakness; nausea and vomiting may occur; the pupils are dilated, the eyes often fixed, the countenance expressionless. In continued hemorrhage these symptoms are all exaggerated, consciousness is lost, tremor or convulsions may be present, the pulse becomes imperceptible, the heart fluttering, and death speedily occurs. DaCosta states that death may be expected if one-half the volume of blood is lost. It often occurs with much smaller hemorrhage if the loss is rapid or accompanied by shock from other causes. "Shock and hemorrhage have so many symptoms in common that it is often difficult to make a differential diagnosis. The question may be a serious one, especially after operations, as it is most important to know whether a given condition of weakness is due to the shock of operation or to concealed hemorrhage, which necessitates immediate operation in order to stop the hemorrhage. In general it may be said that in shock the patient is weak and apathetic, while in hemorrhage he is weak and restless. Frequent examinations of the blood should be made in doubtful cases; a progressive diminution of hemoglobin and the red cells indicates hemorrhage." Treatment for Hemorrhage.—If the dressing shows staining or if there are symptoms of internal bleeding, the surgeon should be notified immediately. The dressing should be "reinforced" by the application of more pads and the bandage or binder may be tightened. A dressing, moist with blood or other body fluids, should never be left exposed as it favors infection and forms an excellent culture medium for germs. The dressing must not otherwise be disturbed until the arrival of the surgeon. In the meantime the patient must be kept absolutely quiet to lessen the work of the heart and prevent increase in blood-pressure. He should have plenty of fresh air. If the bleeding is from an ex- tremity, the limb should be elevated and digital pressure made on the bleeding vessel; if the bleeding is internal, and in any case to relieve systemic symptoms, the head may be lowered, the trunk and extremities being elevated to cause more blood to flow to the brain to supply the vital centers. An ice-bag may be applied over the bleeding area. No stimulants should be given. Preparations should be made for what the surgeon may be expected to need on his arrival. Morphin is usually ordered at once to quiet the patient. The local treatment may include changing the dressing, searching for and ligating the bleeding vessel, packing the wound and applying pressure, and irrigating with a very hot or cold solution. Sometimes, to give the heart more blood to pump and keep the blood where it is vitally needed, the limbs are temporarily deprived of blood by bandag- ing from the fingers and toes toward the heart. These measures 550 THE PRINCIPLES AND PRACTICE OF NURSING in the ward may be only temporary for immediate control, the patient being taken later to the operating room, where the wound is reopened and the bleeding vessels ligated. After the hemorrhage is controlled, to increase the volume of blood, the patient may be given direct transfusions of blood, an intravenous injection, or a hypodermoclysis of normal saline solution. Heat is applied to the extremities and hot fluids are given by mouth or by rectum. To relieve thirst and supply the tissues with fluid, water may be given freely by mouth or by rectum. Later, to aid Nature to repair the loss, the patient must have rest, fresh air, sunlight, nutritious food, and tonics. Usually iron and arsenic are given to increase the hemoglobin and stimu- late the blood-forming organs. TRANSFUSION A transfusion is the transfer of blood from one person (the donor) to another (the donee or recipient). It has proved of great value in the following conditions: 1. Following a severe hemorrhage. 2. In hemophilia and other conditions with lessened coagula- bility of the blood. 3. In severe anemias (and leukemia). In secondary anemia it restores the volume of blood and tides over an emergency until the blood-forming organs can replace the loss. In pernicious anemia, an incurable disease, it gives temporary relief and pro- longs life. 4. In collapse or shock from any cause. 5. In malnutrition or marked prostration. 6. In septicemia, in severe toxemia from sepsis, gas poison- ing (carbon monoxid, etc.), or acid intoxication. Some of the poisoned blood may first be withdrawn and replaced by the donor's blood. 7. Before an operation when the patient is in a very weak- ened condition. 8. In patients suffering from malignant growths in order to increase their general resistance so as to guard against other diseases, such as pneumonia. Effects of the Treatment.—Its advantages over the saline infusion are said to be that, (1) It supplies nutritive material, oxyhemoglobin, and carbon dioxid, and tends to overcome acap- nia (diminished carbon dioxid in the blood), in shock; (2) it does not transude so quickly from the blood vessels, and is not so quickly excreted as saline, and therefore maintains the blood- pressure in hemorrhage longer and causes increased coagula- bility of the blood. There are various theories explaining the undoubted benefits derived in pernicious anemia, but the chief benefit is said to be its stimulating effect, especially on the bone-marrow. Dr. Vogel states that "in the opinion of most authors, the transferred blood TREATMENT FOLLOWING AN OPERATION 551 acts as a stimulant, especially to the blood-forming organs, and, at least for a time, revives the power of blood regeneration." There are certain difficulties and dangers encountered in a transfusion which necessitate the greatest caution, both in select- ing and securing a donor, and in the method of collecting and transferring the blood. They are: 1. The difficulty in securing a donor, also the expense in- volved. 2. The danger of the blood clotting during the transfer. 3. The danger of injury to the blood vessels. 4. The danger of transferring diseases, such as syphilis. 5. The danger from incompatibility of patient's and donor's blood. 6. The possible collapse of the donor, and in some cases the veins of the recipient are small, collapsed, buried, and easily torn, making the treatment difficult. Before using the donor's blood, to avoid the dangers of 4 and 5 above, it is very carefully examined. The following tests are made: A red and white blood cell count, hemoglobin determina- tion, a platelet count (platelets are concerned with the clotting of blood), a Wassermann test to exclude the possibility of con- veying syphilis, a test for "grouping," and a test for isohemo- lysins and iso-agglutinins. The test for grouping is based on the following conclusions. It is a well-known fact that the blood of animals cannot be injected into human beings without producing serious or even fatal results. It is now also known that the blood of one indi- vidual when injected into another may cause very serious results, even though they be members of the same family. It has been shown, however, by different authorities that human blood can be classified into four groups, and that each individual will fall into one of these four groups. The greatest number fall in group four, next in group two, next group three, the least number being in group one. Thus standardized serum for each group may be obtained and kept in the laboratory. The blood of donors will- ing to contribute is then matched up with these standards, or "grouped." The blood of the patient is also "grouped" in the same way. Several classifications have been used to designate blood groups. The two most widely used are the Jansky and the Moss classifications. It is very important in grouping a patient and a donor that the same system of classification be used for both, as serious results might occur through confusion. Therefore in reporting the blood group of any individual the clas- sification used should always be stated, as follows: Blood Group 1, Moss classiflcation. If the donor and the patient belong to the same group some doctors think it safe to transfuse the patient. Some doctors, however, to avoid the danger of incompatibility and a possible reaction, further safeguard by testing for iso- agglutinins, that is, testing the effect of the patient's serum on the blood cells of the donor, and the effect of the donor's serum 552 THE PRINCIPLES AND PRACTICE OF NURSING on the blood cells of the patient to find if they are "mutually congenial." Iso-agglutinins are substances in the serum of the blood which will cause agglutination, or clumping together, of the cells in blood of the same species; iso comes from the Greek word isos, meaning equal or the same. Iso-agglutinins in the patient's serum would clump together the blood cells, injected from the donor and vice versa. In either case the treatment would prove very harmful. Another test sometimes done is for isohemolysins (iso, the same; lysis, to destroy), or poisons in the serum which would destroy red blood cells (hemolysis). Many doctors now con- sider this unnecessary as, in the absence of iso-agglutinins, iso- hemolysins are believed also to be absent. If the donor can be secured the tests can be completed in from one-half to one hour. The amount of blood injected will depend upon the donor, the condition of the patient, and the purpose for which it is given. When given to stimulate the bone-marrow, as in pernicious anemia, it is believed that small amounts repeated as the con- dition demands, give better results than when large amounts are used and that larger amounts may even be injurious (Dr. Vogel). The usual dosage for infants varies from 80 to 150 c.c. and for adults from 500 c.c. to 1000 c.c. In some hospitals or laboratories, in the study and treatment of pernicious anemia a very interesting test called "vital stain- ing" is done as a means of studying the activity of the bone- marrow in forming new red blood cells. Following a transfusion it is done to determine the beneficial or stimulating effect of the treatment on the bone-marrow. The "vital staining test" is based upon the fact that by a special method of staining red blood cells a network of fine threads or reticulations is seen in young cells so that the per- centage of reticulated red cells in the blood indicates the activity of the bone-marrow and its capacity to replace red blood cells. In the blood of infants these reticulations are found in from 5 to 10 per cent, of the red cells, and in the normal adult in from 0.5 to 2 per cent., while in severe anemia they may form 18 to 20 per cent, of the red cells (Dr. Vogel). Following the transfusion if the percentage of reticulated cells is not increased, it shows an inability of the bone-marrow to respond to stimulation. Methods of Transferring Blood.—Having secured a suitable donor, there are several methods by means of which blood may be transferred. It may be transferred directly by means of a special apparatus which connects the artery of the donor to a vein of the recipient. This method is called the "Unger Method" after Dr. Unger, who perfected it. It requires a great deal of skill and practice on the part of the operator. Its disadvantages are said to be that it takes considerable time and so is very TREATMENT FOLLOWING AN OPERATION 553 trying for both donor and patient. The blood vessel becomes injured and it is difficult or impossible to estimate accurately the amount of blood transferred. Another method, the "Lindeman method," is accomplished by means of several 20 c.c. syringes with a special set of cannulas, devised by Dr. Lindeman, by means of which even small veins may be entered easily with little danger of injury. Three oper- ators perform the treatment. One withdraws blood into a syringe from the donor and passes it to the second doctor, who injects it into a vein of the recipient, then passes the empty syringe to the third operator, usually a nurse, who washes it out with sterile saline solution before passing it to the first doctor. This is repeated until the desired amount is given or until the donor shows signs of weakness. This can be done quite rapidly by experts with little danger to either patient or donor, and the amount withdrawn and injected can be accurately reckoned. The third method is called the "citrate method." It consists in withdrawing the blood from the donor into a flask (warm) containing sodium citrate which prevents the blood from clotting. The blood in the flask is stirred very gently with a glass rod in order to mix the citrate evenly without causing injury to the cells or clotting. This may be kept several hours. It is in- jected into a vein of the recipient in the same way as a saline infusion. A flask of normal saline will also be necessary. The saline is first injected to insure that the needle is properly in- serted in the vein and after the blood is injected to insure that all the blood will be washed from the tubing and needle into the vein so that none will be lost. The "citrate method" is now used very extensively, and dur- ing the recent war was a means of saving many lives. The results from this method are said, by those who use it, to have been satisfactory. The amount given is accurately known. It occasions the least inconvenience and is the least energy- and time-consuming for both donor and recipient. It is the least difficult method and is best adapted to ordinary practice, and therefore serves a wider use. It is particularly valuable in cases of emergency as, for instance, where used for the purpose of replacing blood lost in a severe hemorrhage. Those who advocate the direct method of transfusion either by the "Unger" or "Lindeman" methods claim that there are disadvantages in the use of the "citrate method." They claim that febrile reactions and chills occur in a much higher percent- age of cases than where unmodified blood is used as in the direct method of transfusion. It is thought that the difference in reac- tion is due to an abnormal condition of the blood platelets and the red cells in the citrated blood. Some authorities believe that blood acquires toxic properties in direct proportion to the path it has travelled toward coagulation, and that even though it does not absolutely coagulate, changes take place as it is poured from 554 THE PRINCIPLES AND PRACTICE OF NURSING the vessels which render it less suitable. The chemical altera- tion caused by the addition of the sodium citrate is said to in- crease the fragility and the tendency to hemolysis of the red cells. In the direct method it is claimed that the lessened amount of handling and the shorter time that the blood is out of the body lessen its progress toward coagulation and therefore the harmful changes in its character. Whatever method or technique is used, needless to say, it must be conducted with the most strict aseptic precautions. Method of Procedure.—During the withdrawal of blood the donor should be in the recumbent position, made thoroughly comfortable, and allowed to remain in this position for some time following the treatment. Any nervousness on his part should be dispelled. His color, pulse, blood-pressure and gen- eral condition should be carefully watched, and stimulants should be in readiness and used if necessary. An extra blanket, and ice water, etc., should be at hand. An increase in the respirations and pulse rate, yawning or deep sighing indicate that the withdrawal of blood should be discontinued. Pallor and sweating sometimes occur followed by collapse. For the withdrawal of blood the following articles are usually used: A rubber to protect the bed, sterile towels, a disinfectant for the skin, sterile cotton, sterile albolene (to coat the inside of needles, etc., to make the surface smooth and prevent clotting), needles, rubber tubing, a glass graduate to receive the blood, sodium citrate solution, 3 per cent., a small glass graduate with which to measure the citrate (50 c.c. of citrate solution are used to 500 c.c. of blood), a basin of warm water in which to stand the flask to keep the blood warm, a glass rod, and a sterile dressing. The method of withdrawing the blood will be the same as that given under "phlebotomy," Chapter XXII. The recipient must also be made quite comfortable and kept very quiet during the treatment. Restlessness and jerking of the arm make it very difficult to proceed, and may cause injury to the vein, displacement of the needle, hemorrhage, and loss of blood. The patient's color and pulse should be noted before the injection. During the treatment it is very satisfying and fas- cinating to watch the color gradually appearing in the finger nails, and lips, etc., and to note the increasing strength of the pulse. The patient should be closely watched for symptoms of over- dosage. An injection of too much blood may cause pulmonary edema and death. The symptoms of overdosage are distress about the heart, headache, backache, pains in the legs and a short, sharp cough. The latter symptom, particularly, indicates that only a limited amount of blood should be injected following it in order to avoid the danger of overdosage. The method of injecting the blood will be the same as that given under "Intravenous Infusion." TREATMENT FOLLOWING AN OPERATION 555 INTRAVENOUS INFUSION An intravenous infusion or injection consists in the introduc- tion of a solution into a vein. Infusion comes from the word "fundere," to pour, and "in," meaning into. Conditions in which an Infusion is most Commonly Given.— 1. In hemorrhage to restore immediately the volume of blood to normal, and to maintain the normal blood-pressure. This increased volume and pressure mechanically stimulate the heart and increase the supply of blood to the vital centers in the brain. 2. In shock and collapse to stimulate the circulation. 3. In postoperative conditions or in diseases such as cholera to restore the volume of blood and supply fluid to the tissues depleted by vomiting, purging and perspiration, etc. 4. In toxemia to dilute the poisons, to flush the kidneys and carry away the poisons. In severe shock or collapse sometimes small amounts of a solution containing adrenalin are given. Adrenalin contracts the blood vessels and raises the blood-pressure. As the fluid is injected directly into the blood stream it affects immediately the blood, the heart, the brain, and all the tissues of the body, so that the solution used, its temperature, volume and the method of introduction are all vitally important. The effects of an intravenous infusion will depend upon whether the volume of blood has previously been decreased or not. 1. When the volume has been reduced by a severe hemor- rhage, by persistent vomiting or excessive purging, etc., the effect is to increase the volume of blood, raise the blood pressure, and stimulate the heart and circulation. Dr. Crile states that an infusion of saline also shortens the coagulation time of the blood and therefore helps to check bleeding, so that it is valuable to replace blood lost and may be safely used whether a hemorrhage has stopped or not. 2. When the volume of blood has not been decreased by hem- orrhage, etc., a saline infusion has little, if any, effect on the blood pressure, because, as explained by Dr. Bastedo, "in normal ani- mals the tendency of the blood to regain its normal condition is so pronounced that almost as soon as an infusion is begun the mechanisms for regulation are started. As the result of in- creased pressure in the capillaries there is an immediate out- pouring of weak lymph, and this is followed by elimination of liquid through the intestines and kidneys (Starling), so that in half an hour not only will the volume of the blood have returned to normal, but its constituents will have regained their proper relative proportions" (Crile). This explains its use in toxemia, in uremia, in pneumonia, in diabetic coma, and its value in relieving thirst, and supplying nutrition in all cases where tissues are in immediate need. The solutions used are: 1. Normal salt solution.—This con- 556 THE PRINCIPLES AND PRACTICE OF NURSING tains 0.9 per cent, of sodium chlorid. Even slight variations from this strength may be dangerous. Sodium chlorid main- tains the proper osmotic relations between the cells and the fluids in the body, but while it is safely and very commonly used, it does not supply other salts—calcium and potassium—neces- sary to the tissues. The conclusions drawn from many experi- ments (Howell) are that sodium maintains the proper osmotic relations between the cells and fluids of the body. Calcium stim- ulates the heart muscle. Potassium is essential to maintain the rhythmical beat or contraction and relaxation of the heart. 2. Locke's Solution.—This contains sodium chlorid 0.9 gm.; potassium chlorid, 0.042 gm.; calcium chlorid, 0.024 gm.; so- dium bicarbonate 0.03 gm.; dextrose 0.1 gm., and distilled water sufficient to make 100 c.c. This is the best solution because it contains the necessary salts and is alkaline and nutritive. It, therefore, supplants blood which may have been lost (or with- drawn because impure), and it supports the heart. 3. The Ringer-Locke Solution.—The above formula with the dextrose omitted. 4. Ringer's solution contains sodium chlorid 0.7 per cent. (normal for frogs, etc.) with potassium and calcium chlorid. 5. Dawson's solution contains sodium chlorid 0.8 per cent. with sodium bicarbonate 0.5 per cent. In diabetic coma, a 4 per cent, solution of bicarbonate of soda is sometimes given intravenously to neutralize the acidity or to increase the alkalinity of the blood and thus relieve the acidosis to which the coma is due. In the very emaciated, in pneumonia, in gastric ulcer, carci- noma, and operations on the alimentary tract a 10 per cent, glu- cose solution is sometimes given intravenously to supply the tissues with nourishment in a form that can be quickly utilized to produce heat or energy. To understand the effects of these solutions and to appreciate how vitally important it is that they should be accurately pre- pared, it is necessary to recall the uses of salts in the body, the behavior of fluid in the body—the processes of filtration, diffu- sion and osmosis—and the nature and effects of isotonic, hypo- tonic, and hypertonic solutions. Diffusion.—All fluids (or gases) when brought into contact or when separated by a permeable or semi-permeable membrane tend to seek an equilibrium, that is, to become solutions having an equal specific gravity or osmotic pressure or, in other words, containing equal proportions of the substances in solution. This process is called diffusion. For instance, if a solution of salt or sugar (which passes readily through membranes) is separated by a membrane from water, the water will readily pass through the membrane and the salt or sugar will also pass through but more slowly so that in time the bulk of the solution and the pro- portion of salt or sugar will be equal on either side of the mem- brane. The passage of molecules of water through a membrane TREATMENT FOLLOWING AN OPERATION 557 is called osmosis. The passage of molecules of salt or sugar, etc., through a membrane is termed dialysis. When there is a forcible passage of materials through membranes due to differ- ences of mechanical pressure, the process is termed filtration. Throughout the body there are aqueous solutions separated by membranes. For instance, the walls of the capillaries (an endothelial membrane) separate the blood from the lymph which bathes and nourishes the tissue cells; the epithelial lining of the lungs separates the air in the air sacs from the blood in the cap- illaries; the epithelial lining of the kidney tubules and the lining of all secreting glands separate the blood and lymph from the fluids which they secrete or excrete, and the lining of the stomach and intestines separates the digested food and other products from the blood and lymph. Through these membranes water and solids pass, impelled by the necessity to equalize their os- motic pressure. In addition to the processes described must be mentioned the selective capacity of the cells, the power to select or reject substances brought to them in solution. This process is not understood. The absorption and assimilation of food and oxygen, the se- cretion of glands, the excretions from the body and the life and activities of the cells all depend upon these processes. What- ever interferes with the equilibrium of the body fluids interferes with the functions and endangers the life of the tissues. If, therefore, a solution is injected into the blood stream, in which the proportion of salt is greater or less than that of the blood or lymph, this equilibrium will be disturbed and the tissues and blood cells greatly damaged or destroyed. If the solution injected contains an equal percentage of salt, it is said to be isotonic with the blood and no disturbance of osmotic pressure occurs. If it contains a larger percentage of salt, it is called a hypertonic solution. This will cause the blood to abstract water from the tissues, thus depriving the cells of necessary fluid, producing great thirst, loss of vitality, or even death. The plasma of the blood will contain a greater percentage of salt than the red blood cells, therefore water will pass from these cells to the plasma, causing the blood cells (the oxygen carriers of the blood) to shrink, shrivel or become crenated. If the cells are not destroyed equilibrium will later be reestablished. If, on the other hand, the solution injected contains a lower percentage of salt than the blood, it is called a hypotonic solu- tion. The blood plasma will be more dilute than the fluid within the blood cells and water will pass from the plasma to the cells, causing them to swell and burst, setting free the hemoglobin. This destruction of red cells is called hemolysis and the process is called laking the blood. Fluid from the blood will also quickly pass out through the walls of the congested capillaries into the kidneys, the intestines, and into the tissues. If not eliminated fast enough by the kidneys, etc., a general edema will result, with edema of the lungs, which may prove fatal. 558 THE PRINCIPLES AND PRACTICE OF NURSING The effect of these solutions, varying in osmotic pressure, may be readily understood by thinking of an illustration familiar to all. When prunes are purchased at the grocery store, we see that the outside skin or membrane is wrinkled or shrivelled— it has become crenated. This is because water has been ex- tracted from the prune in order to preserve it (bacteria cannot live without moisture). Before cooking the prune, it is put to soak in water and soon the wrinkles disappear, the prune swells up, and the skin may rupture, due to the absorption of water (osmosis). The prune contains substances, in a very concen- trated solution, not contained in the water, which is therefore a hypotonic solution. We see also that the water slowly becomes discolored and if we taste it, it will have the flavor of the prune, showing that solids passed out through the membrane (dialysis). This is exactly what happens to the blood cells or any cells when a hypotonic solution is injected into the blood stream. Again, prunes, or seeds, or fruit of any kind exposed to dry air become shrivelled because they contain more moisture than the air so that water will pass through their skin or membrane in the effort to reach an equilibrium. This is the effect on the blood cells or tissue cells when surrounded by a hypertonic solution, one in which the amount of water in proportion to the amount of salts in solution is less than that in the cells or, more correctly speak- ing, one in which the amount of salts in proportion to the amount of water is greater than that in the cells. Dangers involved in an Intravenous Infusion.—It is evident. then, that this treatment is accompanied by considerable danger to the patient, and it has been reported that "several cases of death have occurred from the use, by rectum or intravenously, of concentrated stock solutions of sodium chlorid in mistake for normal saline" (Bastedo). There is also the danger of injury to the vein followed by phlebitis with thrombus formation and embolism, the introduc- tion of bacteria causing septicemia, and of the introduction of air, and of foreign matter causing a very serious reaction endan- gering the life of the patient. This reaction is best described by Dr. Hare as follows-—"As the injection is given the pulse begins to improve, the respirations are deeper and less hurried, and if fever is present the temperature usually falls. The patient is evidently better "but soon enters a critical stage, particularly if the water has not been properly prepared, which may come on in from two to thirty minutes. There are sometimes a violent chill, a strong, rapid pulse, and in the course of three-quarters of an hour a flushing of the skin, followed by profuse sweat. The respirations may be labored. The urinary flow is also increased, and sometimes water escapes from the bowel. These symptoms rarely occur if freshly distilled water is used." "Recent re- searches have shown that many of the untoward effects which follow injections are due, not to the entrance of the fluid, but to the fact that the water, even if sterilized by boiling, contains TREATMENT FOLLOWING AN OPERATION 559 the toxic products of bacteria or fungi which are primarily pres- ent in the water. The water should therefore be distilled in- stead of boiled and used as soon after distillation as possible." The temperature of the solution should be from 110° to 118° F., heat being a valuable stimulant. The amount of solution given will depend upon the condition of the patient, the purpose for which the treatment is given, or the effect desired. In some cases 200 to 500 c.c. may be given and, again, from one to five pints may be slowly introduced, according to the necessities of the case. (Brewer.) The Procedure.—Preparation of the Patient.—The veins into which the injection is given are the median cephalic or the me- dian basilic, in front of the elbow, which is usually the largest, the most prominent and nearest to the surface. To prepare the part the following articles will be needed: a dressing rubber to put under the arm to protect the bed, sterile towels to cover the rubber and the immediate area around the elbow, a tourni- quet (to apply around the upper arm to shut off the return of blood by the superficial veins making the veins at the elbow prominent), and disinfectants to sterilize the skin. When ap- plying the unsterile tourniquet see that the loose ends are di- rected upward so that they will not be in the way or contami- nate the area or any sterile article. A good light is also abso- lutely essential. The instruments and utensils needed will depend upon the method used. The solution may be poured from a graduated glass into a glass funnel connected by rubber tubing, etc., to the infusion needle or it may be made to flow by gravity or siphonage directly from a glass flask through the rubber tubing, connecting tip and needle, etc., into the vein. The latter method will be described under "hypodermoclysis:' on page 561. When the first method is used the articles required will be the glass graduate containing the solution and a sterile ther- mometer to test the temperature; a glass funnel, rubber tubing with a small metal connecting tip on the end to fit into the needle and having a glass connection in the rubber tubing through which air bubbles in the solution may be detected, also a clamp to shut off the flow, infusion needles, sterile cotton pledgets, a paper bag and basin for soiled pledgets or instru- ments, a sterile dressing and adhesive or bandage to retain it. If the arm is fat, the veins embedded or collapsed, it may be necessary to incise the skin and expose the vein. For this will be needed, in addition, a hypodermic loaded with cocain 2 per cent., a scalpel, an aneurysm needle, artery clamps, catgut, probe, scissors, needle holder, dressing forceps, suture silk and needles. Method of Procedure.—After the needle is inserted in the vein, the tourniquet is loosened. Air is expelled from the tubing and while fluid is running the tubing is attached to the needle. The injection must be given very slowly, the funnel being held from one to three feet above the head. Dr. Hare advises one 560 THE PRINCIPLES AND PRACTICE OF NURSING foot above the arm and states that at least thirty minutes should be used in injecting as much as a quart. Where a flask is used (second method) the nurse must see that the solution does not drop low enough to allow air bubbles to enter the tubing, and that the temperature of the solution is maintained by adding, if necessary, hot solution. She should also watch the patient's color, pulse, and breathing, and keep a record of the amount of solution given. This is charted with a report of the effect noted upon the patient. The procedure is conducted under the most sterile aseptic precautions. The doctor wears gloves, and everything, except the dressing rubber and tourniquet, must be sterile. This treatment is contraindicated when edema is present. As explained previously, when the volume of blood is not reduced, an infusion has a tendency to cause edema. If the fluid cannot pass out quickly from the capillaries into the tissues, an injec- tion of fluid into the veins may cause dilatation of the right side of the heart and pulmonary edema, which might be fatal. It is indicated when rapid action is desired, when the circula- tion is poor, and when the tissues are unable to absorb fluid. When this is not the case the same effects may ultimately be secured either by giving the injection into the tissues (hypoder- moclysis), or into the rectum (proctoclysis). Effects by hypo- dermoclysis are secured more rapidly and directly than by proc- toclysis. HYPODERMOCLYSIS A hypodermoclysis is a method of supplying fluid to the body by injecting normal saline, or Locke's solution, into the sub- cutaneous tissues. The word "hypodermoclysis" is derived from hypo, meaning beneath, derma, the skin, and the Greek word klysis, already explained. It is also derived from the word "clysmian," which means having the character of a deluge or to drench. The therapeutic uses of a hypodermoclysis are much the same as those described under an intravenous infusion, so need not be repeated. The effects of the treatment are also much the same, the dif- ference being chiefly in the rapidity with which the results are obtained. The fluid injected is rapidly absorbed by the blood vessels, especially after a hemorrhage, with results identical, although not so rapidly obtained as when given by intravenous injection. It is said that a quantity of liquid equal to four times that of the normal amount of blood may be passed directly into the veins without producing a rise of blood-pressure and that usually an increased flow of urine from the kidneys occurs within fifteen minutes after fluid flows into the subcutaneous tissue. (Dr. Hare.) TREATMENT FOLLOWING AN OPERATION 561 The treatment, like an intravenous injection, is contraindi- cated in any form of edema. The solutions used are the same as when given intravenously. The temperature of the solution is 120° F. The amount of solution may be from one to two pints, given slowly. "It is not safe to infuse a greater quantity of liquid than one dram to each pound of body weight in each fifteen minutes, as, if this amount is exceeded, the accumulation of the liquid in the system is so great that the tissues become drowned, because the kidneys cannot excrete the liquid fast enough." Site to be Prepared.—The solution may be introduced be- neath the skin of the abdomen, below the breast, in the thighs, buttocks, or in the axillary line. The articles required for the treatment will be a rubber dress- ing sheet, sterile towels to drape the area, disinfectants for the skin, sterile absorbent cotton, the sterile solution, thermometer, flask, tubing (with glass connecting tip to detect air bubbles) and needles. Sometimes injections are made in two places simul- taneously; in that case a glass T connecting tip with two short pieces of rubber and two needles will be required. A sterile dressing—a collodion dressing or gauze and adhesive—a paper bag and kidney basin will also be required. The kind of flask used varies. Sometimes an open sterile flask into which the solution is poured and allowed to run out by gravity through the rubber tubing, etc., attached is used. Sometimes the flask containing the sterile solution ready for use (when heated) is used. This flask is provided with a rubber stopper with two holes into which glass tubes are inserted. One tube extends into the solution. To this tube the rubber tubing, etc., is attached. The other tube does not extend into the solution. To this a bulb is attached by means of which pressure is exerted on the solution which is in this way forced through the other glass tube into the rubber tubing and needles, etc., attached. Method of Procedure.—The flask should be held or secured about two feet above the patient. The doctor connects the sterile tubing, etc., disinfects the skin, and inserts the needles. The nurse's duties are to prepare the patient, to assist the doctor as required, to watch the rate at which the fluid is absorbed, to see that the fluid does not become too low, and as it may run in very slowly, to see that the temperature is maintained. As the fluid enters a slight local swelling develops which disappears as absorption takes place. Very gentle rubbing will aid the absorp- tion. When this treatment is given, the condition of the patient is frequently critical. The greatest care must be taken to avoid exposure and chilling. The nurse should watch the patient's color and pulse closely. In charting, note the amount of solution given and the effect of the treatment on the patient's pulse, appearance, and gen- eral condition. 562 THE PRINCIPLES AND PRACTICE OF NURSING WOUND INFECTION Another important duty of the nurse in the care of a patient following an operation is to provide, as far as possible, condi- tions which promote healing of the wound, to watch for any symptons of infection, inflammation, congestion and suppura- tion, and to exclude all conditions which predispose to it. Conditions which Promote Healing and Prevent Suppura- tion.—A wound is a "solution in the continuity of soft tissues." The wound made in a surgical operation, if infection does not already exist, is an aseptic incised wound, that is, it is made by a sterile, sharp, cutting instrument and the tissues are sharply di- vided without tearing or laceration. When the edges of such a wound are brought together, nicely adjusted without puckering, and held together by sutures, wound clips or strips of sterile ad- hesive, etc., then covered with a sterile dressing so applied, pro- tected and sealed as to exclude all possibility of the entrance of bacteria, it should heal by direct or primary union or by first intention. Healing by first intention means that the cut edges grow together or heal with the slightest inflammatory reaction and with the least requirement for the formation of new tissues. This occurs because merely the cells in the direct line of the injury are destroyed. Bleeding occurs between the cut edges and a small amount of blood may remain and form a clot. The blood supply will be increased and a small amount of coagulable fluid will ooze out. This also clots and glues the edges together. Epithelial cells and connective tissue cells divide and form new cells to replace the injured cells. The endothelial cells of the walls of the capillaries sprout or send out bud-like processes which stretch across and join similar sprouts from the other side. Endothelial cells divide, forming new cells, and the pressure of blood hollows them out into tubes. In this way new blood ves- sels are formed and the circulation is established. Leucocytes remove the few dead cells. Later a small amount of new con- nective tissue is produced which forms a scar, in this case almost or quite imperceptible. If healing is to take place in the above manner a nurse must see that no restless movements of the patient, exertion or strain, as in coughing or vomiting, etc., cause a rupture of the sutures with tearing open of the wound. She must also see that the dressings are not displaced, exposing the wound or even the area around the wound. The next essential is the proper nutrition, which means a rich supply of normal blood freely circulating in the part. The patient's diet, his surroundings, general health and comfort have a very marked influence on the nutrition and cir- culation in the part and it must not be forgotten that the mental attitude also influences to a marked degree the metabolism and functions of the whole body. The effect of sugar in the blood (diabetes), or increased acids (acidosis), and anemia from malnutrition, old age, or lowered TREATMENT FOLLOWING AN OPERATION 563 vitality from any cause has already been explained. Any inter- ference with the circulation, whether from high blood-pressure, arteriosclerosis, or pressure from tight bandages or adhesive straps, etc. (which either limits the supply of blood or causes congestion), interferes with healing and may result in death of tissue, infection and suppuration. When the circulation is free, bacteria, which are always present in every wound, no matter what precautions are taken, are easily overcome by the tissues and healing is rapid. These bacteria, however, at other times harmless, multiply rapidly when in the presence of dead tissue or fluid in a congested area. Even the pressure from sutures drawn too tightly in the wound is sufficient to cut off the circu- lation and is likely to result in infection and suppuration. Wounds in tissues where the blood or lymph supply is free, as in the face, heal much more rapidly than in tissues such as ten- dons, ligaments, or cartilage, etc., where the blood supply is limited. For the same reason epithelium (the skin, etc.) heals more rapidly than deeper structures such as muscles and fascia, etc., so that superficial wounds heal more rapidly than deep wounds. This is chiefly due to the fact that epithelial tissue has such a wonderful power of regenerating itself or multiplying and forming new tissue while muscular tissue has very little. Wounds in young people heal more rapidly than in the aged, in whom the circulation is poor and the vitality lower. Wounds in old people must, therefore, be watched with particular care and in any case when a bandage, splint or cast is applied to an extremity (where the circulation is apt to be poor) a nurse must watch for discoloration, pain, cold sensation, and swelling indi- cating poor circulation. An intact nerve supply is equally important to the nutrition of the part so that pressure must never be so great as to cause loss of sensation or numbness. The position of the part must be such as to promote good circulation. We have already learned the effect of pressure, poor quality of blood, abnormal constitu- ents in the blood, poor circulation and paralysis in both the cause and delayed healing of bedsores. The same applies to any wound. In some cases, such as ulcers on the leg, a tight bandage applying pressure is used in order to prevent conges- tion in a dependent part and to aid the return circulation of venous blood. In an abdominal wound or dressing the nurse must note increased pain and distention which causes the ad- hesive straps to become so tight that the pressure may be suffi- cient to limit the blood supply or cause congestion in the wound. Increased fluid in the part, the action of bacteria, inflammation and suppuration, will cause increased tenderness, an elevated temperature, a rapid pulse, and an increased leucocyte count (leucocytosis). These are the symptoms a nurse should watch for. They may be due to a stitch abscess, that is, inflammation and a mild suppuration about one or more stitches. If, how- ever, the above symptoms are not observed or are ignored and 564 THE PRINCIPLES AND PRACTICE OF NURSING the suppurative process is allowed to continue, the accumulation of fluid and pus will cause the sutures and tissues to slough, allowing the wound to burst open with a free discharge of pus. It may cause ligatures to slough and slip from the blood vessels leading to a secondary hemorrhage. The bacteria and poisons may also be absorbed into the blood stream and cause a general sepsis which may prove fatal. Such a wound must heal by indirect union. Healing by Indirect Union or the Formation of Granulation Tissue.—When, from any cause, the edges of a wound cannot be brought together so that a gap remains between them which must be filled in by the formation of a considerable amount of new tissue (granulation tissue), repair is said to take place by indirect union. The repair may be a sort of patchwork, some- times even quite unsightly, and without restoring the function of the part, because several kinds of tissues may be injured and tissues vary greatly in their power to regenerate themselves. The epidermis and connective tissues are only slightly special- ized and so regenerate rapidly. The central nervous system, the muscle of the heart and blood vessels, and all striated muscles are highly specialized and regenerate themselves hardly at all so that any gap made in these tissues must be filled in by in- ferior tissue which can grow fast and restore the continuity although not the function. The universal tissue used for patch- ing is the fibrous connective tissue which is strong but not so elastic or so well supplied with blood vessels. This is why in- flammation or injury to the tissues of the brain, the walls of the heart or blood vessels, and of other internal organs, is so serious. In the brain even this repair cannot be made because there is so little of this connective tissue there: A wall merely is formed around the diseased part so that, as it is carried away, a space is left which is gradually filled in with fluid, forming a cyst. The degree of the protective inflammatory reaction which fol- lows depends upon the injury and whether or not infection is present. Immediately the surface of the wound or cavity is covered by a thin layer of fibrinous exudate. This thin fibrin forms a valuable protection as it has been found that, while bac- teria are absorbed within a very short time by lymph and blood vessels from fresh bleeding wounds, as soon as this coagulum has been formed, bacteria are no longer quickly carried into the blood and lymph circulation. It also helps to check bleeding, which, in addition, is checked by the clotting of the blood and the contraction of the blood vessels. The exposed surface tends to contract with the formation of this coagulum and this aids in closing the wound and in bringing the edges together. As the inflammatory process sets in, with an increased supply of blood, fluid and white blood cells are poured out which coag- ulate, forming a network of fibrin. This fibrin acts as a support or guide for the connective tissue cells which stretch out by ameboid movements along it. Sprouts of endothelial cells from TREATMENT FOLLOWING AN OPERATION 565 the capillaries also stretch out into the network of fibrin and as new endothelial cells are formed, they are spread into tubes by the pressure of blood. Connective-tissue cells divide and grow out along the fibrin and surround and support the new capil- laries. Capillaries anastomose or join other capillaries, forming tiny arches which form little pinkish elevations, giving the sur- face an uneven, granular, velvety appearance. This all takes Fig. 130.—Characteristic Growth of Connective Tissue Cultivated in Vitro. There are many mitotic figures. (From MacCallum's "Text- book of Pathology," W. B. Saunders Co., Publishers.) place very rapidly so that the advance can be watched from day to day. This granulation tissue, then, consists of abundant blood ves- sels and young connective-tissue cells spread apart by fluid and fibrin. When healthy it is soft gray or grayish-red, gelatinous, and translucent, with an irregular, velvety surface, bleeding at a touch, but quite insensitive to pain because containing no nerves. Although the surface of a healthy granulating wound offers great resistance to bacterial invasion, this resistance may 566 THE PRINCIPLES AND PRACTICE OF NURSING be broken down by very slight injuries, such as probing, the removing or the shifting of a dressing, etc. The skin edges also tend to turn inward and may act as a wick carrying in infection. Sometimes healing is delayed or indolent—the tissue is then pale, dry, shrunken, flabby and unhealthy looking. Sometimes it grows too fast. It is then said to be redundant and is soft, large and bleeds easily. The granulations should form from the Fig. 131.—Characteristic Growth of Epithelium in Culture. (From MacCallum's "Textbook of Pathology," W. B. Saunders Co., Pub- lishers.) bottom and sides of the wound, filling in the gap evenly until even with the surface. Sometimes it grows above the surface and must be removed with caustics, or sometimes there is a tendency to grow faster and therefore close in at the top first. This is prevented by putting in drainage to keep it open. When the gap is nearly filled a thin grayish blue film of epithelium may be seen spreading out from the edges to cover the surface "much as ice in its first formation spreads out from the edges TREATMENT FOLLOWING AN OPERATION 567 of a pond." The epithelial cells behind divide, multiply and push the others forward until finally the surface is covered. It is at first bluish but later white. The specialized structures such as secreting glands and hair, etc., are not formed. When a wound is extensive or the formation of the new epithelium is slow, frequently a "skin graft" is made. Connective tissue, then, covered by epithelial tissue forms the Fig. 132.—Epitheuum and Connective Tissue Growing Side by Side in a Culture Made From the Intestine of an Embryo. (From MacCal- lum's "Textbook of Pathology," W. B. Saunders Co., Publishers.) bulk of the new material used for repair. At first the tissue looks purplish under the pearly epithelium because of the abun- dant blood vessels—this is particularly marked on exertion,, which increases the blood supply. As the connective tissue is completed many of the new blood vessels are pressed shut and disappear and the part becomes very white (because of the lack of specialized pigment cells) and hard and is then called the scar or cicatrix. As the tissue is inelastic it causes a contraction 568 THE PRINCIPLES AND PRACTICE OF NURSING of the part and, if extensive, as in a severe burn, is apt to cause deformity or, as in an extensive operation for the removal of the breast, loss of function of the arm. Later the contracted tissue stretches out somewhat, so that the deformity, etc., is lessened, and nerves again develop in it. If healing takes place by either of the above methods without interference and no other complication arises, the patient's tem- perature should return to normal after the first two or three days and local tenderness should disappear. Immediately after the operation the temperature may be subnormal but as the reaction Fig. 133.—Growth of Epithelium Over a Granulating Surface. Irregu- lar dovvngrowths of epithelium are an index of the delay in the heal- ing. (From MacCallum's "Textbook of Pathology," W. B. Saunders Co., Publishers.) sets in it is elevated for the first few days and the pulse shows a corresponding elevation. If it remains elevated and the wound is very tender and sore, one should suspect infection with in- flammation and possible suppuration. An elevated temperature following an operation may be due to other causes besides the wound, such as pneumonia or auto- intoxication. Pneumonia will be discussed later. Auto-intoxi- cation is due to the absorption of the products of fermentation and putrefaction of contents in the intestines. In this condition the temperature and other symptoms subside after the intes- tines are cleansed by an enema. Complications Which May Occur in the Healing of Wounds. — (1) Scar formation with contraction resulting in deformity or loss of function. (2) Keloid, that is, an actual tumor formed in the surface of a scar due to the over-activity of the connective tissue. (3) Ulcer formation, that is, a raw surface caused by a more or less extensive necrosis of the skin or mucous membrane due to poor circulation, poor nutrition from interference with the nerve supply, lowered vitality, diseases such as diabetes or TREATMENT FOLLOWING AN OPERATION 569 nephritis and other causes. (4) Sinus formation, that is, the formation of a channel, lined with a pyogenic membrane, extend- ing from an abscess to the skin, mucous membrane or wound. The abscess may be due to bacteria or to sloughing or dead tissue such as a piece of dead bone (sequestrum), or it may be due to a ligature left in and not absorbed or a wipe or other for- eign body accidentally left in the wound. Irritating bile or urine will also form a sinus. The channel will remain persistently open and will discharge until the foreign matter is removed. (5) Fistula formation, that is, an artificial channel which connects a gland, duct or hollow organ, either with the exterior or with another gland, duct, or hollow organ. The most common are the intestinal or fecal fistula, gall-bladder fistula, renal fistula and fistulae of the urinary bladder. They are usually due to some obstruction to the normal passage of the contents of the organ, duct or gland. CHAPTER XXXIII THE PREVENTION, TREATMENT AND NURSING CARE IN POST-OPERATIVE COMPLICATIONS In addition to the discomforts and other serious conditions, directly due to the operation itself, which have been discussed in the previous chapters, dangerous complications sometimes follow in its train if not carefully guarded against. These complica- tions will be discussed in the present chapter. They may result from an infected wound as in cellulitis, septicemia, pyemia, ery- sipelas, tetanus, and peritonitis, or they may bear no relation to the wound, as in post-operative pneumonia, renal complica- tions, thrombo-phlebitis and pulmonary embolism. Such diseases are not only always very serious in themselves, and often fatal, but when following in the train of an operation, they attack the patient before his body has had time to recover from the injury, shock, loss of strength, and lowered resistance due to the operation. Careful, intelligent nursing and the early recognition and re- porting of symptoms will often prevent the development of these dangerous complications. In the care of patients following operations nurses should consider it their particular province and should take a special pride in seeing that their patients have a speedy, uneventful recovery. COMPLICATIONS RESULTING FROM INFECTED WOUNDS Cellulitis,—When the suppurative process infiltrates the sur- rounding tissue the condition is called cellulitis. The organisms which produce cellulitis are more commonly the streptococci, the staphylococcus aureus or albus and the colon bacillus. Where the tissues are loose the infection spreads very rapidly. Cellu- litis may result from the spreading of infection already present in a post-operative wound or from the invasion of the wound by bacteria. When not associated with a post-operative wound it may be due to infection following an injury to the tissues re- sulting from friction, heat or cold, counterirritants, injections of irritating drugs, and snake or insect bites. Even a pin prick if it introduces the germs, may be followed by a serious and even fatal cellulitis. When it occurs in patients where the circula- tion is poor as in marked arteriosclerosis, or when the metabolism of the tissues is interfered with and the blood is abnormal as in 570 TREATMENT IN POST-OPERATIVE COMPLICATIONS 571 diabetes or when the nutrition of the tissue is poor as in spinal cord lesions, cellulitis may be rapidly fatal. Sometimes a pa- tient's resistance is poor to special kinds of infection. The symptoms are both local and general. The local symp- toms are those of an acute inflammatory process—heat, redness, swelling, intense throbbing pain, and loss of function. The gen- eral symptoms are due to absorption of toxins or septic material and are the general symptoms which accompany fever or sepsis. The local symptoms often resemble the early symptoms of ery- sipelas so that it is difficult to make a diagnosis until the de- marcation in erysipelas is well established. Cellulitis may be mistaken for erysipelas or vice versa. Both spread very rap- idly. When there is doubt as to the diagnosis the patient should be put "on precautions" as in the treatment of erysipelas. (See Erysipelas, page 573. The treatment usually consists in the application of moist dressings or a continuous bath where possible and surgical inter- ference by incision and drainage. Septicemia, Pyemia and Septic Intoxication.—Septicemia or acute general sepsis is the result of the entrance, growth, pro- liferation or general flooding of the blood stream with pyogenic organisms. Pyemia is septicemia in which the organisms have gained a foothold here and there in the tissues of the body in which they deposit colonies or suppurative foci of infection (abscesses) from which bacteria are from time to time poured into the blood stream. Septic intoxication or toxemia is due to the absorption of toxins from the suppurating wound or abscess. Sapremia is a general poisoning due to the absorption of poi- sons due to the action of putrefactive organisms on dead tissue. An example of this would be puerperal sepsis due to the action of organisms on a portion of the placenta allowed to remain in the uterus after childbirth. The tissue being cut off from the blood supply dies and so forms an ideal lodging place for bacteria. The organisms which most commonly cause septicemia are the streptococcus pyogenes and the staphylococcus aureus or albus. These bacteria are always present in the mouth, throat, nasal passages, etc., and on the skin,-and the lowered resistance of the patient due to the operation invites an attack. Whatever lowers the general resistance of the patient or the resistance of the wound tissues predisposes to septicemia. The streptococci cause a general septicemia or they may at- tack the walls of the blood vessels, forming infected thrombi from which, as they disintegrate, the bacteria are shed into the blood. An example of this would be septicemia due to sinus thrombosis following a mastoidectomy. This thrombus at first may form a plug preventing the invasion of the general blood stream with bacteria but as it disintegrates (perhaps not until 572 THE PRINCIPLES AND PRACTICE OF NURSING the end of a week or more) shreds laden with bacteria pass into the stream, giving rise to the chill, high temperature, etc., of general sepsis. Streptococci, which grow in chains, cause a diffuse inflammation. Wherever they gain a foothold they "tend to spread diffusely through the tissues, causing havoc wherever they go." The staphylococci, on the other hand, cling together in clus- ters, so concentrate their attack at various points where they produce abscesses with an acute inflammatory reaction around them. They cause osteomyelitis and produce small abscesses on the surface and throughout the organs of the body—the muscles, heart, liver, and kidneys, etc. In a general infection these organisms are discharged in the urine, which is, therefore, a source of danger. Other organisms—the pneumococcus, gonococcus, bacillus coli communis, bacillus pyocyaneus, and others, may be the cause of septicemia. The symptoms usually begin on the third post-operative day with chilly sensations or a definite chill, headache, and back- ache, and the patient feels very miserable in general. The tem- perature rises to 102°, 105° or 107° F. The mouth is dry, the lips parched, the tongue coated and the patient is very thirsty. The high fever may be continuous but more often there are marked remissions, rising after a chill (probably due to a pour- ing out or flooding of the blood stream with fresh bacteria) and falling to or below normal during the cold sweats which occur. The pulse is rapid and, as the lining and muscles of the heart and blood vessels become affected, soft, small and easily com- pressible. As the kidneys become affected the urine is scanty. Red cells are destroyed causing the marked pallor, and bacteria plug the capillaries with emboli, forming petechial spots. While the patient's resistance lasts there is a marked leucocytosis which falls as the general prostration increases. In fatal cases restlessness and delirium alternate with stupor which finally passes into coma before death. The local symptoms are pain and acute inflammation about the wound. Treatment and Nursing Care.—The local treatment consists in a thorough drainage, cleansing and irrigation of the wound or focus of infection. When the symptoms are due to toxemia they subside with the local treatment but when due to general sepsis they are not relieved by the local treatment. In septi- cemia and pyemia the prognosis is very grave but patients have recovered with proper treatments and skilled nursing care. Transfusions are given to supply antibodies and to increase the patient's resistance. Hypodermoclyses and proctoclyses are given to stimulate the heart, supply fluid to the tissues, relieve thirst dilute the poisons, stimulate the kidneys and to flush the poisons and bacteria out of the system. Water is also given freely by mouth. Nourishing fluids are given by mouth or when nausea and vomiting prevent, nutrient enemata are given. Everything TREATMENT IN POST-OPERATIVE COMPLICATIONS 573 is done to keep up the patient's strength and resistance and to cause the elimination of the poisons. Fresh air and sunlight are essential. Everything must be done to relieve discomfort—the headache is relieved by an ice-cap, the backache by massage and by rubbing with alcohol, chills by the application of external warmth, the high fever, restlessness, delirium or stupor by cool sponging. The mouth is kept moist and clean, perspiration is removed by sponging, the gown and bed linen are kept dry and clean. Skilled nursing care will do much toward keeping up the pa- tient's strength and preventing him from being overwhelmed by the invasion of the bacteria. A patient with septicemia or pyemia should be isolated from other surgical patients and every precaution taken to prevent the spread of infection. The nurse must avoid or take great care of even the slightest abrasions which she, herself, may have, for bacteria may enter by the most minute abrasion, even too small to be visible, and cause a general septicemia even before the local symptoms develop. Erysipelas is an acute infectious disease, characterized by a rapidly spreading inflammation, which usually attacks the skin but which may spread to the mucous membrane of the throat, larynx, or middle ear, etc. It is caused by the streptococcus pyogenes, usually called the streptococcus erysipelatis, which ac- counts for the diffuse, spreading inflammation. It always begins in a wound or abrasion, most commonly on the head or face, but also on the abdomen and other parts. The organisms are con- stantly present in the nose and sinuses, which is said to account for the frequency with which erysipelas occurs *on the face fol- lowing a slight abrasion or an operation on the mastoid cells or facial sinuses. Symptoms.—The streptococci invade the tissues and occur in large numbers in the lymph channels of the skin. The wound becomes hot, tender, and red; the skin becomes red, elevated, smooth, tense and edematous with an advancing, irregular, red, glistening and sharply defined margin which marks the advance of the streptococci. As the army keeps advancing it leaves be- hind only dead organisms so the inflammation gradually sub- sides and the color fades in the devastated region passed over. Suppuration, however, sometimes occurs. Where the skin is loose, as about the eyes, the tissues may become very edematous and enormously swollen—the skin may become necrotic or great blisters may form. Where the skin is tight, the spread of the infection is checked. The constitutional symptoms are also marked and are the same as in general sepsis—chill, fever, rapid pulse, etc., leucocytosis, and frequently delirium. Patients usually recover from the erysipelas but may die from septicemia or pneumonia. Treatment and Nursing Care.—The disease is self-limited— the organisms die as they advance—so must run its course. The 574 THE PRINCIPLES AND PRACTICE OF NURSING temperature usually falls in four or five days. The patient is isolated as the disease is very infectious. Local applications are made, such as ichthyol or cold wet dressings of boric acid, which do not cure but which give great comfort. The nursing care is the same as in any septic or toxic condition and is directed toward relieving all possible discomforts and to building up the patient's strength and resistance. Erysipelas is very apt to recur. No immunity seems to be developed. Like all coccal infections—pneumonia, gonorrhea, etc.—once having gained a foothold, these organisms are very difficult to dislodge so that one attack predisposes to future attacks. Tetanus occasionally occurs as a complication following sur- gical operations. The tetanus bacillus is sometimes present in the intestinal canal of both men and animals. Some are in this way thought to be carriers. In abdominal operations in which the intestines are bruised, roughly handled or exposed and chilled so that their resistance is lowered or when the wound is con- taminated with fecal material, tetanus may develop if the tetanus bacillus is present. The catgut used has also occasionally been a source of infection. Catgut is made from the intestines of sheep and so may be contaminated with the tetanus bacillus. The normal habitat of the tetanus bacillus, however, is in the soil, so that accidental wounds contaminated with dirt, etc., are more apt to be infected. Tetanus will, therefore, be discussed under accidental wounds. Peritonitis.—Before one can understand the post-operative conditions in which peritonitis is likely to develop and, therefore, know when to particularly guard against it; or before one can recognize and understand the symptoms, or realize the serious- ness of the disease or understand the treatments used both to prevent and relieve peritonitis, one must recall certain facts about the peritoneum. The first point to remember is its enormous extent, its surface if spread out being almost equal to that of the skin. Infection, therefore, may spread very rapidly and extensively but this is, to some extent, limited by the anatomic divisions formed by folds of peritoneum and the arrangement of the organs, etc., and also by the ability of the peritoneum to form adhesions and thus wall off or localize any inflammatory process. This is ac- complished within a few hours by the pouring out of a fibrinous exudate which glues two inflamed surfaces together and which, if necessary, is later changed into dense, strong, permanent fibrous adhesions. This ability to form adhesions is greater in some regions than in others, particularly in the pelvic region, so that infection or a collection of pus may be quickly walled'off and its spread limited. This explains why a patient is placed in Fowler's position fol- lowing an operation for an appendiceal abscess, etc., as it causes the fluid or pus, if present, to gravitate to the pelvis, where it TREATMENT IN POST-OPERATIVE COMPLICATIONS 575 can be localized and drained. There is also another reason for putting a patient in Fowler's position—the pelvic peritoneum has a much greater resistance to and is less susceptible to in- fection and its power of absorption is less than in other regions. The peritoneum contains many lymph glands so has an enor- mous power of absorption, particularly in the peritoneum of the upper abdomen, so that by keeping the infection away from this region the danger from the absorption of bacteria and toxins re- sulting in septicemia or toxemia, is lessened. The healthy peri- toneum has a wonderful resistance to bacteria but when ex- posed to chilling, drying, rough handling or pressure during an operation or to irritation due to bile, stomach. and intestinal contents or to strong antiseptics or to the presence of blood or foreign bodies such as ligatures, sponges or instruments acci- dentally left in, its resistance is greatly lowered and its power of absorption is decreased so that bacteria, at other times harm- less may stagnate, multiply, and cause peritonitis. This power of absorption is due to the numerous lymph chan- nels whose business it is to carry away waste products, bacteria and other foreign substances. The direction of the flow may be reversed so that the peritoneum may pour out a large amount of lymph or inflammatory exudate—this accounts for the rapid accumulation of fluid in this cavity. The pouring out of the exudate forms adhesions, prevents toxemia, dilutes toxins and helps to flush out the cavity. Drainage tubes inserted or any foreign body acts as an irritant and causes an increased flow, therefore aids in localizing the infection and in drainage. Plain gauze is the most irritating and causes the greatest outflow, but is seldom used alone or, if used, is generally removed within twenty-four hours because if left in too long the fibrinous exu- date infiltrates its meshwork, binding and sealing it in so that it merely dams back the pus, and makes it very difficult, painful, and injurious to the tissues in removing. If left in a week it may easily be removed because by that time the tissues around it will have broken down with the formation of an abscess so that the gauze lies loosely in a pocket of pus. This reverse flow of lymph, etc., causes a loss of body fluids which must be supplied in the treatments. Another important factor to remember is that the parietal peritoneum (lining the abdominal wall) contains many sensory nerves while the visceral layer does not, so that inflammation of the parietal layer causes extreme pain and tenderness. This ac- counts for the extreme tenderness of the abdomen, so great, some- times, that the least pressure of the bedclothes may be unbear- able. It also accounts for the hard, board-like rigidity due to the contraction of its muscles in the effort to protect the viscera within, to keep the parts absolutely at rest and so avoid pain, irritation and the spread of the infection. It also accounts for the shallow costal breathing as the diaphragm is kept quiet in order to avoid pressure, irritation or the least movement of the 576 THE PRINCIPLES AND PRACTICE OF NURSING viscera within. Again it accounts for the position instinctively assumed by the patient—the shoulders bent and the knees drawn up to prevent any pull or strain on the abdominal muscles with increased pain. In peritonitis the muscular coat of the intestines and its nerve plexus are involved so that paralysis results with constipation or obstruction, fermentation and putrefaction of its contents with distention or tympanites. This pushes the diaphragm up, makes breathing difficult and embarrasses the action of the heart. It also causes severe pain and strain on the sutures. Causes of Peritonitis.—The conditions which predispose to infection or which cause a non-infective type of peritonitis have already been mentioned—exposure, rough handling, etc., per- foration of an abdominal organ resulting in the presence of irri- tating or decomposing substances such as blood, bile, urine, and stomach contents, etc. Stomach contents are irritating but may be free from pathogenic organisms except when, as in cancer, hydrochloric acid is diminished or absent. Contents of the small intestine are very irritating on account of the pancreatic juice which digests anything it comes in contact with. The contents may also be highly infectious as in typhoid fever. The contents of the large intestine always contain many bacteria and are highly infectious. Acute septic peritonitis may be caused by perforation in appendicitis (contents from the large intestine), in typhoid and gastric ulcer, by rupture of an abscess of the liver, kidneys, Fallopian tubes or ovaries, by inflammation spreading from other tissues, and by infection of an abdominal wound. The organisms which most commonly cause septic peri- tonitis are the streptococcus pyogenes, the staphylococcus, colon bacillus, gonococcus, typhoid bacillus, tubercle bacillus and the pneumococcus. Symptoms.—The first is constant pain. Note its location and character. When due to a perforation, it is usually very sharp and sudden, and accompanied by persistent vomiting, usually projectile in type and requiring no effort on the part of the pa- tient. The vomitus consists first of stomach contents then, as the intestines become paralyzed and obstructed, regurgitation and vomiting of fecal matter occur. There is always tenderness and rigidity of the abdomen—note its location and whether spreading or not; other symptoms are a rapid, weak, thready, compressible pulse; an elevated temperature (in advanced cases it may be subnormal); rapid, shallow respirations; a rising leu- cocytosis; hiccough, due to irritation of the diaphragm; disten- tion, due to paralysis and fermentation of intestinal contents; a characteristic position—knees drawn up; prostration and symp- toms of general toxemia—face pinched, anxious looking, drawn and blue, tongue coated and tremulous, sordes on the teeth, rest- lessness, mind active and alert, sleeplessness, and finally there may be delirium, stupor or coma. The treatment is suggested by Nature's method and attempt TREATMENT IN POST-OPERATIVE COMPLICATIONS 577 to relieve pain, to localize and prevent the spread of infection by keeping the viscera absolutely at rest and by getting rid of irri- tating contents within; to relieve pain, etc., by position; to dilute poisons and flush out the cavity by the pouring out of fluids, and by efforts to increase the resistance (leucocytosis). To limit peristalsis and so keep the parts at rest, absolutely nothing is given by mouth, not even water, and at first enemas, or even the insertion of a rectal tube, are avoided. To get rid of irritating contents, the stomach is frequently washed out by lavage. This relieves pain, vomiting, distention, restlessness, and sleeplessness and limits peristalsis. To relieve pain and localize the infection, an ice-bag or ice-coil is usually applied. This must not be left on too long as it may limit the blood supply and lower the resistance. Sedatives are also given to relieve the pain, restlessness, and sleeplessness; morphin, which also limits peristalsis, may be ordered. The position is very important. It must be such as to localize the infection in the pelvic cavity, promote drainage and relieve strain on the abdominal muscles and sutures. Fowler's position is used by many surgeons. The patient sits upright, properly supported and prevented from slipping down, the knees are flexed and supported—this can best be accomplished with a Gatch frame. Remember that this is a very trying position. A nurse will have to use every art to make the patient comfortable and to prevent bedsores. Remember also that this position causes increased work for the heart. Also see that the shoul- ders are properly covered, for the limited action of the dia- phragm in addition to the usual causes of post-operative pneu- monia, predisposes to this condition. In this position, when distention is present, there is less pressure on the diaphragm and therefore less difficulty in breathing. The patient may lie on his back or on his side if the pillows are comfortably ar- ranged—comfort is extremely important in conserving the pa- tient's strength and resistance. Frequent sponging and rubbing with alcohol give great relief. Fowler's position does not aid in drainage because the pus will be in the pelvis and would have to run uphill to the wound (drainage is accomplished by the drainage tubes, etc., used) so sometimes to aid drainage the patient is turned on his face, comfortably supported with pil- lows, so that the pus will naturally run out. Some surgeons do not use Fowler's position at all but turn the patient on his face immediately after the operation. A hypodermoclysis, proctoclysis and, if necessary, an intra- venous infusion are given to supply the body with fluids, to re- lieve thirst, to keep up the resistance, to dilute and eliminate toxins and to flush the kidneys. Colon irrigations and enemata are given to relieve distention. A cradle is used to relieve the weight of the bedclothes when they cause discomfort. The dressing to the wound should be changed frequently, both to avoid irritation to the skin and tissues and the odor 578 THE PRINCIPLES AND PRACTICE OF NURSING which, if the patient is not too prostrated, is very distressing and adds to his discomfort. A little aromatic spirits of ammonia or eau de cologne sprinkled on the bed is both stimulating and refreshing. Some surgeons do not use dressings at all over the wound in drainage cases but use the open treatment; that is, a cradle is used to prevent contact of the bed linen, etc., with the wound (an electric light is sometimes attached for warmth and comfort), and a large absorbent dressing is placed snugly at the patient's side to absorb the pus as it drains from the wound. The skin is protected by sterile vaseline or zinc oxid, etc. If the feeling of the contact of clothing is necessary to sleep, large dressings are applied to the wound during the night. As in the care of all post-operative conditions, all causes of discomfort and unrest either mental or physical should be re- moved. As in all abdominal operations all causes of intra- abdominal tension should be avoided in order to relieve pain and strain on the sutures—coughing, sneezing, vomiting, disten- tion, retention of urine, sudden movements or straining at stool, etc. Diet.—When anything by mouth is allowed, it should be given with the utmost care to avoid the danger of vomiting and dis- tention. Water is usually given for twenty-four hours, then, if no unfavorable symptoms occur, small amounts of fluids con- taining carbohydrates are given to prevent acidosis. Acid in- toxication sometimes develops after an operation, particularly when the patient is deprived of food for some time. In order to supply energy the patient is then obliged to try to burn up his own fat and when this difficult form of metabolism is incom- plete, it results in the accumulation of fatty acids or acidosis. If carbohydrates are given they will be used to form energy and so prevent acidosis. The care of the mouth is important in all post-operative con- ditions but particularly so in all abdominal operations. POST-OPERATIVE PNEUMONIA Pneumonia is a serious complication which occasionally de- velops after an operation although with proper care before, dur- ing, and after the operation it can always be prevented. Where there is no pre-existing cause it is the result either of a poor anesthesia or of poor nursing. Where there is a predisposing factor such as inflammation of the upper respiratory tract__ coryza or bronchitis, or disease or congestion of the lungs as in tuberculosis and some forms of heart disease,—ether anesthesia is avoided. It depresses the respiratory center, increases the local irritation and congestion and so forms a suitable soil for the invasion and growth of bacteria. The prognosis in pneumonia in the old or very young is bad and in all cases it adds greatly to the discomfort of the patient. The coughing causes severe pain and a serious strain on the TREATMENT IN POST-OPERATIVE COMPLICATIONS 579 sutures of the wound and in every way makes the outlook less favorable. The preventive measures to use before the operation are to see that the mouth, nose and throat are well cleansed; to avoid exposure and chilling of the body during the preparation of the patient and in all other treatments; to see that old people par- ticularly have plenty of bedclothing so that they will not be chilled by the scanty cotton nightgown and lack of underclothing which they may have been accustomed to; and to see that the patient is quite warm when going to the operating room. A prolonged anesthesia is always to be avoided when possible. The preventive measures while the patient is under the anes- thetic and later are, to keep the mouth, nose and throat free from mucus, vomitus, or blood, and to prevent their inhalation. Avoid exposure. Be particularly careful to see that the patient is well covered when coming from the warm operating room— the chest and the extremities particularly must be kept warm. A padded jacket as chest protector is usually worn under the gown. Avoid exposure during restlessness. Ether causes a dila- tation of the blood vessels in the skin and perspiration. Chill- ing of the surface of the body would cause these vessels to con- tract thus driving the blood to the interior and causing conges- tion of the lungs and other internal organs. Allow no damp clothing near the patient such as gown or bed linen wet with perspiration. See that the room is quiet and warm (68° F.), with plenty of sunlight and fresh air but no drafts. Particular care must at all times be taken with old people. They must not be allowed to lie long on their back, must be turned frequently, placed in a semi-recumbent position, given a backrest and allowed up as soon as possible. All patients should be turned as often as their condition permits. Particular care must also be taken after operations on organs high up in the abdomen, such as the stomach, liver, and gall bladder, because the handling, exposure and irritation of the upper peritoneum and the diaphragm predispose to pneumonia. These patients are usually propped high up in bed. No tight binder or strap- ping, etc., should be allowed to limit the movement of the lower ribs as this also predisposes to pneumonia. Loss of blood also predisposes to pneumonia. The symptoms which suggest pneumonia are rapid respira- tions, an increase in the pulse rate, an elevation of temperature, and frequently a cough. They usually appear on the third or fourth day. Post-operative pneumonia is usually bronchitic or broncho- pneumonic in type although lobar pneumonia occasionally de- velops. The grouping of the sputum usually shows group IV pneumonia, that is, a mixed infection—the streptococcus, micro- coccus catarrhalis and influenza bacillus may be present. These are organisms commonly found in the nose and throat. The treatment in addition to the preventive measures already 580 THE PRINCIPLES AND PRACTICE OF NURSING given consists in keeping the air warm and moist—steam in- halations give great comfort; the use of sedatives (codein) to relieve the cough and strain on the sutures; water in abundance to drink, and the prevention of distention. Local applications to the chest, such as mustard pastes and cupping, also give relief. The patient should be kept absolutely quiet, free from worry or excitement. The treatment for lobar pneumonia is the same as that out- lined in the chapter on medical diseases. RENAL COMPLICATIONS SUPPRESSION, ANURIA, UREMIC COMA Following the administration of a general anesthetic the kid- neys may fail either totally or partially to secrete urine. Ether and chloroform are irritating poisons which must be eliminated from the body. They irritate all the tissues they come in con- tact with. A large amount is eliminated by the kidneys, so they may become irritated. Inflammation sets in and, as you re- member, one of the symptoms and results of inflammation is loss of function. The function of the kidneys is to secrete urine. Also as a result of the anesthetic the kidneys are forced to eliminate other irritating, abnormal waste products which re- sult from incomplete metabolism. You will remember that the anesthetic causes depression or checks the functions of every organ and all the processes of oxidation. When these processes are complete relatively harmless substances are formed which do not irritate the kidney cells such as carbon dioxid, water and urea, etc. When incomplete, only partially broken down or com- bined, the substances formed, such as ammonium compounds from protein, acids from fats and sugars, are harmful, so that the work of the kidneys is not only increased but the products eliminated are very irritating and may result in loss of function. A nurse must, therefore, be particularly on her guard to watch the amount of urine and the urinalysis following an operation and to note immediately any symptoms of suppression—scanty urine, of low specific gravity, headache, dizziness, dimness of vision, nausea, poor appetite, restlessness and sleeplessness, and puffiness under the eyes. Finally, the patient may become drowsy and weak, with muscular twitchings and delirium and in fatal cases convulsions and coma may develop before death. The treatment and preventive measures consist in the avoid- ance of all exposure, the administration of forced fluids by mouth hot colon irrigations, proctoclysis with potassium acetate (a di- uretic), imperial drink and other diuretics and diaphoretics and the applications of counterirritation to the lumbar region such as mustard pastes, hot flaxseed poultices, fomentations or dry cupping. If anuria develops, hot packs are given to increase the elimination of waste products by the skin, thus protecting TREATMENT IN POST-OPERATIVE COMPLICATIONS 581 the body and resting the kidneys. These treatments are entirely in the nurse's hands. Their success and the recovery of the pa- tient depend largely upon the skill with which they are given. ACIDOSIS Acid intoxication or acidosis sometimes develops after an operation. This is due to the accumulation of fatty acids— (3-oxybutyric and diacetic acid, etc., resulting from the incom- plete metabolism of fats. The patient must have some source of energy so that when nourishment is withheld after the opera- tion the body attempts to burn up its own supply of fats. The symptoms are dyspnea or rapid breathing, poor appetite, persistent nausea and vomiting. If not relieved the condition may become acute, resulting in coma and possibly death. The Treatment.—To prevent acidosis and to supply nourish- ment when the patient cannot be given fluids by mouth in suffi- cient quantity, a glucose solution is usually given by proctoclysis or in urgent cases it may be given intravenously. This is to supply the tissues with sugar, which can easily be converted into energy. As soon as possible carbohydrates are given in the diet to prevent further metabolism of the body fats. THROMBOPHLEBITIS AND PULMONARY EMBOLISM During an operation blood vessels are cut, bruised, clamped and injured in various ways. When blood vessels are injured or if foreign matter—air, bacteria, shreds of tissue, etc.—enter the blood stream, the blood tends to clot. When the small blood vessels are cut, the blood clots to check the bleeding. During an operation, therefore, there may be numerous small blood clots formed. A clot within a blood vessel during life is called a thrombus. Thrombi most frequently form in the veins where the blood flows more slowly than in the arteries and most commonly in the left saphenous or femoral veins. They are more frequent after abdominal operations, especially on the uterus and in operations about the rectum. They usually occur about the second or third week after operation. Thrombi form on the walls of the vessel and, if undisturbed in this position for some time become firmly fixed to the wall of the blood vessel. Connective-tissue cells which grow into the thrombi finally replace them completely with fibrous tissue. This is called organization of the thrombus which ren- ders it relatively harmless. New channels may be formed in it for the passage of blood so that instead of flowing through one channel it flows through several smaller channels or entirely new channels may be formed by anastomosing branches. If, 582 THE PRINCIPLES AND PRACTICE OF NURSING however, violent movements or rubbing or rough handling, etc., dislodge the thrombus before it is organized it will be carried in the blood stream into the larger veins to the right side of the heart and thrown violently into the pulmonary artery and then into one of its branches too narrow to pass, where it be- comes tightly wedged, completely obstructing the flow of blood. If this occurs in a large pulmonary artery instant death usually results. A thrombus which is dislodged and carried in the blood stream until it becomes lodged in a vessel which it completely obstructs is called an embolus. Pulmonary embolism is one of the most distressing accidents which may occur during conva- lescence, occurring usually when least expected, without any pre- vious warning or time for treatment because there have been no symptoms of thrombus formation. It may occur suddenly when sitting up in bed or in a chair or walking around for the first time. The symptoms of thrombophlebitis are local tenderness and swelling, or the whole limb may be swollen and painful with a sensation of weakness and weight. If the clot is infected there may be a slight chill, a rapid pulse, and an elevated temperature. The Treatment.-—Free movements after an operation help to prevent the formation of thrombi. In old people, particularly, or in patients with a weak heart, lowered vitality or varicose veins, long rest in bed tends to cause the formation of thrombi. If formed, the patient must be kept very quiet, in bed in the recumbent position, and the part must be kept absolutely at rest for from five to six weeks. Even very slight movements or exertion may be sufficient to dislodge the thrombus. No strain- ing of any kind, such as straining at stool, should be allowed. On no account should the part be rubbed. The limb may be wrapped in cotton and elevated or elevated on a soft pillow to aid the return flow of blood and a hot-water bottle placed at the feet. A cradle should protect the part from the bedclothes. An ice-bag applied to the part relieves the inflammation and pain. When the acute symptoms subside a hot-water bag gives relief. Sedatives are usually necessary for the severe pain. Particular care must be taken to avoid the slightest movements after the third week, when the clot is likely to disintegrate. An infected thrombus always disintegrates so that the whole or shreds of it may be dislodged. CHAPTER XXXIV THE NURSING CARE IN OPERATIONS REQUIRING SPECIAL CARE IN THE AFTER-TREATMENT There are a number of operations which, either because of their nature and location or the complications which may de- velop, require special nursing care in the after-treatment. Some of these will be discussed in the present chapter. The special things to be considered are, the nature of the operation and what to watch for; the position, freedom of movement and comfort of the patient; the diet, general hygienic care, care of the wound and special treatments required. OPERATIONS UPON THE JAW OR MOUTH All wounds about the face heal rapidly because of the free blood supply. In order to avoid disfigurement, primary union is extremely important. Great care must be taken, therefore, to avoid infection of the wound as it would interfere with healing and might leave an unsightly scar, causing contraction and de- formity. In wounds of the face watch for symptoms of injury resulting in paralysis or loss of sensation. In operations on the mouth or jaw, in which the wound penetrates the mucous mem- brane, it is difficult to avoid infection as the mouth is never free from bacteria. The care of the mouth is for this reason extremely important in all cases. It should be thoroughly cleansed every two hours with an antiseptic solution, taking great care not to damage the sutures. The nose should also be kept clean. The Diet.—In order to keep the mouth clean and the parts absolutely at rest until healing or granulations have formed, the patient is usually fed liquid food either by rectum or by gavage. This is necessary also, in operations on the tongue (such as ex- cision in carcinoma), or on the jaw, in which the muscles of the tongue are injured and the patient is unable to swallow. He will learn to swallow later by using other muscles. When the patient is given fluids by mouth through a drinking tube, the fluid should be allowed to enter the unaffected side and the mouth should be carefully rinsed and cleansed afterwards. Operations on the tongue may cause such intense swelling (with edema of the glottis) as to obstruct the breathing so that it is most important to watch the patient's color and breathing. Watch for hemorrhage, either primary or secondary, in opera- tions about the nose, mouth or jaw, particularly in infected 583 584 THE PRINCIPLES AND PRACTICE OF NURSING wounds. The arteries are large and anastomose freely so that hemorrhage is likely to be severe and difficult to control. In- fected thrombi may form and be forced out of the vessels, result- ing in a severe hemorrhage. An ice-bag is usually applied to the face or to an external wound to prevent a hemorrhage and to check suppuration if infection is present. The head should be kept turned over on the side in operations on the mouth to allow all secretions, etc., to flow out easily. Harelip.—In an operation for harelip there is always consid- erable shock and loss of blood. The treatment for these condi- tions must always be included in the after-care. Infection of the wound must be avoided, as it will cause sloughing of the sutures and undo all the delicate work done by the surgeon. The nose and mouth must be kept scrupulously clean. The wound, lips and nostrils are sometimes painted with a 10 per cent, colloidal silver solution or with iodin. The wound must be kept free from crusts by gently sponging with boric acid. Sterile albolene may be used to keep the skin soft and free from crusts. The part must be kept absolutely quiet, if possible. A baby must be kept from crying and his hands must be secured. Feedings are given with a sterile medicine dropper. Watch for hemorrhage. All causes of discomfort, unrest, excitement or sleeplessness, such as soiled diapers, damp clothing, cold, or too much heat, hunger, gas in the stomach or intestines, playing with or talking to, etc., must be avoided. Cleft Palate.—In this operation there is apt to be more shock, a greater loss of blood and greater danger from hemorrhage. The care is the same as in the above. EXOPHTHALMIC GOITER The chief causes of post-operative death are acute toxemia, due to the stimulation or increased absorption of thyroid secre- tion, and pneumonia. Shock may also be severe and occasion- ally hemorrhage. These patients are always very poor surgical risks because the gastric disturbances from which they have suf- fered and the increased metabolism, due to the hyperthyroidism, make them emaciated and depleted. The extreme tachycardia also causes myocarditis, which makes the operation particularly dangerous. During the operation the system is flooded with the thyroid secretion. Either an operation for ligation of the thyroid vessels or a thyroidectomy may bring on acute symptoms of toxemia—extreme tachycardia, a very high temperature 104° or 105° F., and nervous symptoms with sometimes violent excite- ment. Heart failure may result. These symptoms are said to be present in a mild degree in two-thirds of the cases, but usually subside in two or three days. The post-operative treatment is to relieve shock, to prevent pneumonia and toxemia, and to watch for hemorrhage. The pa- tient should have absolute rest in a quiet, dark room. Sandbags AFTER-TREATMENT IN SPECIAL OPERATIONS 585 are placed at the sides of the head and neck to keep the parts at rest and prevent strain on the sutures. Care must be taken to keep the nose, mouth and throat free from secretions and to pre- vent them from being aspirated into the lungs. Some surgeons turn the patient on the face, with the body elevated by pillows, to allow the free outflow of secretions, thus preventing them from entering the lungs or the stomach and causing discom- fort. Elevating the foot of the bed prevents shock and aids in the outflow of secretions. There must be no strain on the sutures. Repeated injections of normal saline solution by hypodermo- clysis are frequently given to relieve shock, to supply fluids to the tissues, and to combat the toxemia. Every effort is made to lessen the thyroid secretion, to prevent its absorption and to cause it to be eliminated from the body. It is extremely toxic to the nervous system, heart and kidneys. It may cause an acute and fatal nephritis. Fluids are forced in every way to dilute the toxic secretions and flush them from the system, by intravenous injections, hypodermoclyses, proctoclyses, colon ir- rigations, and later, forced fluids by mouth. An ice-bag is ap- plied to the neck to check the formation and absorption of the thyroid secretion. Morphin is given to prevent restlessness when recovering from the anesthetic, and the patient is usually kept under the influence of either morphin or bromids to prevent restlessness, nervousness, or excitement. A nurse must remember that her patient is very easily excited and her emotions very easily upset. By studying her patient and by suggestion, tact and skill she may prevent these symptoms of acute toxemia. Every effort must be made to soothe, quiet, encourage, and steady the patient, and to pre- vent mental excitement, worry, or fatigue, as well as all causes of physical discomfort, unrest, or exertion. When the toxemia is acute and the temperature, etc., does not subside, cold or ice- packs are sometimes given to reduce the temperature, quiet the heart and relieve nervousness and excitement. When conscious (if there is no further danger from shock or vomiting, etc.) the head, neck and shoulders may be made com- fortable with pillows. As soon as possible the surgeon usually allows the patient to be propped up. This prevents pneumonia, lessens the strain on the sutures, and makes breathing more comfortable. The irritated mucous membrane due to the ether and the tight constricting dressing make breathing sometimes rather difficult. Steam inhalations are sometimes ordered and give great comfort. Every effort must be made to build up the patient's general condition by sleep, rest, fresh air, nourishing diet, plenty of water, and other hygienic measures. No tea or coffee or any- thing irritating to the nervous system should be given. The patient is allowed up as soon as possible, frequently within a few days. She must not be allowed to become fatigued. 586 THE PRINCIPLES AND PRACTICE OF NURSING A BREAST AMPUTATION Following an extensive breast amputation there is apt to be considerable pain and discomfort in the arm, shoulder, and chest, and also in breathing. Pillows should »be arranged to support the arm and shoulder, to make them comfortable, and to pre- vent strain on the sutures. All operations on the chest predispose to pneumonia and, in addition, the pain and discomfort limit the motion of the chest wall, which also predisposes to pneumonia. The surgeon usually orders the patient to be propped up in bed as soon as possible. Then, as the wound heals, to prevent contraction, with the result- ing danger of a stiff arm and loss of function in the shoulder joint, the patient is encouraged to make slight movements of the shoulder joint, the arm being left free from the dressing for this purpose. Slight movements of the arm are allowed soon after the patient becomes conscious. After the third or fourth day the surgeon usually allows the patient up in a chair. In this position the arm, shoulder and chest can be made more comfortable. The weight of the arm should be well supported. After a few days the patient is al- lowed to feed herself and is encouraged to use the arm so as to exercise the joint. At the end of a week she may do her own hair. After an operation resulting in such an extensive scar and de- formity the patient is apt to be sensitive and depressed. She should be kept as bright, cheerful and hopeful as possible, and never allowed to brood over her misfortune. Give her some- thing else to think about and something to do which will exer- cise the arm and shoulder. Remember thatsa stiff shoulder.joint is a very real misfortune and a serious handicap, and that the only way to prevent it is by proper exercise. ABDOMINAL OPERATIONS After all abdominal operations, with the necessary exposure and handling of the peritoneum and viscera, and, in some cases, a prolonged anesthesia or considerable loss of blood, there is apt to be more or less shock. This danger is particularly great in operations on the organs of the upper abdomen—the liver, gall bladder, and stomach, because of the great celiac plexus and abundant nerve supply in the region of the lesser curvature of the stomach, and because of the close relation to the vital or- gans, the heart and lungs. Pneumonia is also more apt to follow operations on the ab- domen, particularly on the upper abdomen, due to the exposure and handling of the diaphragm and upper peritoneum. No tight binder or adhesive strapping should be allowed to limit the movement of the lower ribs, as this predisposes to pneumonia. Vomiting is more apt to be prolonged and distention is more AFTER-TREATMENT IN SPECIAL OPERATIONS 587 apt to occur because of the exposure and handling of the viscera with resulting paralysis of their muscular walls. The function of the whole alimentary tract may be interfered with and there may be considerable delay before it can resume its normal func- tions. Special care must therefore be observed in resuming and selecting the diet, also in giving either enemas or cathartics. A hernia may follow an abdominal operation in which the union is weak. Intra-abdominal tension from any cause—vom- iting, coughing, sneezing, distention, retention of urine, straining at stool, restless movements—must be avoided, as it causes a strain on the sutures and predisposes to hernia. The patient's position must allow the abdominal muscles to relax to prevent pain and strain on the sutures. She may lie on her back with the shoulders elevated, the thighs and knees flexed and supported, or she may lie on her side, with chest, thighs, and knees flexed. Infection of the wound must be avoided, as it may cause a weak union and predisposes to hernia. All sources of discomfort must be avoided as they cause restlessness, with a strain on the sutures. Adhesions may follow abdominal operations. To prevent ad- hesions and also to prevent pneumonia, the patient should be moved at least two or three times during the day. This also helps to prevent distention. To prevent peritonitis, when there is local infection, care must be taken to localize the trouble by limiting peristalsis and all restless movements and by placing the patient in Fowler's position. When there is drainage either from an abscess or from any organ, the position must be such as to promote free drainage. The skin must be protected from discharges from an abscess or from any of the abdominal organs. The secretions of all the glands—the bile, gastric juice, pancreatic, and intestinal juices —are very irritating to the skin and delay the healing of the wound. Any discharge of the secretions from the small intes- tines is particularly irritating, as it contains the pancreatic juice, which digests whatever it comes in contact with. Discharges from the large intestine are also very irritating and contain pathological and putrefactive germs which may contaminate the wound and cause peritonitis. Disagreeable odors are very distressing to the patient (and other patients) and have a depressing effect on the mind and, therefore, on the whole system. When discharges from any part of the body have a foul odor, the dressings should be changed frequently, the bed linen kept sweet and clean and the patient unembarrassed by the odor. A little cologne water or aromatic spirits of ammonia on a wipe, which the patient can smell, or a little sprinkled over the bedclothes is very refreshing. Red wash (which contains compound tincture of lavender) or a small amount of a deodorizing agent may be sprinkled on the external dressing, binder or bandage, and on the bedclothes; formalin, carbolic acid, creolin, or naphthalin solution may be used. 588 THE PRINCIPLES AND PRACTICE OF NURSING Dressings should be changed every two or three hours when the discharge is foul as in a fecal fistula, and the skin should be kept clean and protected to prevent eczema. Where there is in- flammation with suppuration and drainage in a wound, hot moist dressings give great relief and promote free drainage. Closed wounds free from infection or drainage are usually left undisturbed for from seven to ten days as any unnecessary inter- ference predisposes to infection. The abdominal binder is frequently applied after abdominal operations for comfort and support and to give the patient a feeling of security. It relieves her mind, for it is natural for her to feel that the wall is not quite strong at first. HERNIOTOMY After a herniotomy, particularly, every precaution must be taken to avoid a strain on the sutures. The patient should be moved, to prevent pneumonia, adhesions or distention as in other operations, but with extreme care. In some cases, however, where a weak union is feared, the surgeon may not allow the patient to be moved for some time, sometimes for two or three weeks. In all cases the thighs are flexed slightly and the knees supported to relax the abdominal muscles and prevent strain on the sutures. All restless movements must be avoided. Some- times it is necessary to bind the thighs together and in children or violent patients sometimes a few turns of plaster-of-Paris bandage are applied to protect the wound. In male patients, following a hernia, the scrotum must always be supported. This is done to relax the muscles and prevent strain on the sutures and to prevent congestion in the part which predisposes to infection and other complications. OPERATIONS ON THE STOMACH Gastrostomy.—This consists in the formation of an artificial fistula through the abdominal wall into the stomach and the insertion of a rubber tube or soft rubber catheter through which food may be introduced into the stomach. The fistula may be formed in such a way as to produce a valve-like action prevent- ing any leakage of gastric juice, and also the rapid, spontaneous closure of the wound when the fistula is no longer necessary. The operation is performed so that food may be introduced as high up in the alimentary tract as possible when a stricture or obstruction of the esophagus, such as in carcinoma, prevents food from being swallowed. The tube through which food is to be introduced is clamped off between feedings to prevent any escape of gastric juice. This juice is very irritating owing to the hydrochloric acid and enzymes in it. It prevents healing of the wound and may cause eczema. It does not infect the wound because its acidity is AFTER-TREATMENT IN SPECIAL OPERATIONS 589 destructive to germs. If gastric juice escapes around the tube the parts must be cleansed, protected with an ointment, and the dressings changed frequently. Feeding the Patient.—The method of feeding the patient varies. Some surgeons keep the stomach absolutely at rest for the first twelve hours after the operation, during which time the patient is given nutrient enemata every four hours, alternating with normal saline by enema or the Murphy-drip method. Then nothing is given but sips of water until the second or third day, when such fluids as albumin water, peptonized milk and vichy in small amounts (ounces two) alternating every two hours, mak- ing feedings due every hour, are given. Then the amounts are gradually increased until at the end of a week (healing has taken place) six to eight ounces of fluids are given. Gradually very carefully selected soft diet is given until after two or three weeks a more liberal diet, both in amount and variety, is per- mitted. Rectal feedings are discontinued usually when soft diet is allowed. Some surgeons, on the other hand, believe that the sooner after the operation the patient is supplied with nutrition, the sooner normal digestion and peristalsis will be resumed. Feedings are begun as soon as the anesthetic wears off. Sometimes regular fluids are allowed or sometimes only selected fluids. Peptonized milk is usually given—five ounces every two hours—because it is nourishing and partly digested. Its nutritive value is usually increased by adding dextrose, lactose or whisky, one-half ounce, and sometimes in addition one egg. The Method of Feeding.—All that has been said in a previous chapter regarding the effect of the emotions, of pleasurable sen- sations, bright, cheerful, pleasant surroundings, enjoyment and interest in eating, a good appetite, and everything which pro- motes a good appetite, on the secretions, and on the digestion and assimilation of food, has an added importance when feeding the patient in this artificial manner. Everything possible must be done by the nurse to create these favorable conditions. At its best, to the patient, it is a poor substitute for the life-long cus- tom of eating in the normal way with the natural pleasure and satisfaction which to some people are the chief enjoyments of life. Try to make it as natural as possible, otherwise, pouring the food into the stomach may fail to cause the gastric juice to flow and so will only cause discomfort. These patients are nearly always already emaciated and weakened from being un- able to swallow food for a prolonged period. Some surgeons allow the patient to hold the food in the mouth, to masticate it, if solid, before placing it in the funnel. The sensation of taste and the presence of the food gives pleasure, stimulates the appe- tite and the secretion of both saliva and gastric juice. Warn the patient not to swallow the food. Place a screen around the bed to avoid the depressing effect of embarrassment. When feeding the patient, a funnel is attached to the rubber 590 THE PRINCIPLES AND PRACTICE OF NURSING catheter.. The food is allowed to run in very slowly. Some- times, according to the doctor's orders, about one-half funnel full of water is allowed to run in both before and after the feed- ing. The patient should remain quietly at rest after feedings. When the tube is to be removed after feedings, after all the food has passed into the stomach, the tube is left in position a few minutes to avoid starting up peristalsis. It is then gently re- moved. Whether the tube is removed after, and left out between feed- ings or not, depends upon the method of operation. When the Janeway method is used the tube is left in the fistula for the first five or six days after the operation, that is, until healing has sufficiently advanced. After this the tube is removed, cleansed, sterilized and only introduced when feeding is neces- sary. Surgeons who use this method say that the tube is re- moved between feedings for several reasons—for cleanliness, and the comfort of the patient, and because, if left in permanently the tube becomes eroded by the gastric juice and the fistula tends to dilate, allowing the escape of gastric juice. Normally the valve-like action and the pressure and contraction of the muscular walls of.the abdomen prevent its escape. If the fistula tends to close or become smaller when the tube is removed, it is left in longer or not removed so frequently. It is never left out more than twelve hours. The fistula closes rapidly after the tube is finally removed, that is, when no longer necessary. Many surgeons, however, do not use this method of operation and the tube is not removed for ten days to two weeks or longer, depend- ing upon the case. A nurse should never remove the tube with- out special orders from the surgeon and should prevent any restless movements or disturbance of the dressing which might cause its accidental removal. If the tube should be removed or slip out by accident, the nurse should call the surgeon imme- diately to reinsert it. If not replaced at once the fistula may close and it may be very difficult or impossible to reinsert it. A jejunostomy is a fistula formed into the small intestines for the same purposes as a gastrostomy or when absolute rest of the stomach is desired. The care in feeding is the same as in gastrostomy. A gastro-enterostomy is performed in malignant or benign pyloric stenosis and in certain cases of gastric and duodenal ulcer. A pylorectomy may be performed for the same condi- tions—the after-treatment is the same in each. The after-treatment consists in relieving shock and loss of blood, in supplying the body with fluid and nourishment, in pre- venting toxemia due to acidosis resulting from starvation in keeping the part absolutely at rest until healing takes place and in preventing nausea, vomiting, distention, coughing pain' and all discomforts causing either mental or physical unrest. The principal points to remember are, that there is a fresh wound in the wall of the stomach and of the small intestines AFTER-TREATMENT IN SPECIAL. OPERATIONS 591 which will take several days to heal; that the walls of the stomach are richly supplied with blood vessels, and that in such an extensive operation there is apt to be considerable bleeding into the stomach. The blood accumulates because the stomach is paralyzed by the ether and the operation, and putrefaction of the blood is rapid as it is an excellent medium for germs. The stomach dilates increasing the shock and interfering further with the action of the heart and lungs. The blood and the increased secretions, due to the ether, cause nausea and vomiting; the muscular walls are paralyzed so that nothing passes out, and as there is no absorption nothing should be allowed to pass in. A lavage may be necessary to remove the blood and secre- tions in order to relieve nausea and vomiting. Vomiting is always very exhausting and the patient is always in a weakened condition before the operation because the ulcer or growth is usually one of long standing, so that the patient has been poorly nourished for months or years. Rest, sleep, nourishing diet, fresh air, and freedom from worry, etc., are extremely important after the operation. The Treatment.—Nothing is given by mouth (not even water) for from six to eight hours after the operation and sometimes even longer. A hypodermoclysis may be ordered to relieve shock and to supply the body with fluid. Normal saline or normal saline with glucose solution may be given by infusion or by proctoclysis to supply the tissues with fluid and carbohydrates to prevent toxemia due to acidosis. The feedings vary with the patient's condition and the pres- ence or absence of nausea and vomiting, etc. The following is an example of a method frequently followed: Nothing by mouth for eight hours, then water 3 i is given every hour. alternating every hour. On the first day: Water § ss alternating with albumin water every hour. On the second day: Peptonized milk f, ss Albumin water " Water Broth " On the third day: Beef juice % i every two hours. On the fourth day: Feedings increased to % v and ice cream allowed. On the fifth day: Regular fluids every two hours. On the sixth day: Jelly, junket and custard. On the eighth day: Scraped beef allowed. On the ninth day: Selected soft solids. When solids are allowed the patient should be instructed to eat slowly and to masticate thoroughly. No very hot or cold fluids, etc., should be allowed and no tea or coffee, as they tend 592 THE PRINCIPLES AND PRACTICE OF NURSING to increase hyperacidity. Particularly after an operation for the removal of a gastric ulcer, care must be taken to avoid in- creased acidity, as there seems to be a tendency to a recurrence of the ulcer. Hyperacidity of the stomach contents is usual in gastric ulcer. In carcinoma, hypoacidity is the rule and for this reason the healing of the wound should be watched closely because the absence of hydrochloric acid allows the growth of bacteria so that contamination of the peritoneum and wound is much more apt to cause peritonitis or wound infection than in a gastric ulcer where the acidity is high. Distention is particularly serious after a gastro-enterostomy so must be watched for and prevented. The application of a flaxseed poultice with the insertion of a rectal tube in the rectum and the administration of pituitrin, which stimulates the con- tractions of the intestines, are frequently used to relieve it. OPERATIONS ON THE INTESTINES The care is chiefly directed toward the prevention of peritonitis, the prevention of intestinal paresis with distention or obstruction, the prevention of adhesions, securing proper drainage when necessary, the care of the wound, and the proper use of diet, enemata or cathartics. Discharges from the small intestine are very irritating to the skin and wound because of the presence of the pancreatic juice, but operations on the large intestines are more serious because of the danger of soiling the peritoneum or the wound with the contents which contain many bacteria which may cause peri- tonitis or general sepsis. The prevention and treatment of these conditions have already been discussed. Hemorrhoids.—The after-treatment, as in all operations on the rectum and anus, requires skilled and conscientious atten- tion. The factors to remember in the treatment are the danger of severe hemorrhage, primary or secondary, the danger of infec- tion, the constant severe pain, probable retention of urine, and the need for absolute rest and cleanliness. Hemorrhage from the rectum may be very severe as the blood supply is very free. The bleeding may occur shortly after the operation or after a lapse of several days due to the sloughing of the tissues and erosion of a blood vessel. Watch the dress- ing for staining and also watch for symptoms of shock or col- lapse, because if the bleeding occurs into the rectum and the sphincters are contracted the blood will not show externally but will accumulate in the rectum, giving the symptoms of an internal hemorrhage. The patient may ask to use the bedpan, as contents in the rectum normally produce this desire. The treatment for a hemorrhage consists in keeping the patient AFTER-TREATMENT IN SPECIAL OPERATIONS 593 very quiet and warm, elevating the foot of the bed, reinforcing or changing the dressing and applying pressure. Inserting ice may help to control it. The surgeon should be sent for im- mediately. The patient should be prepared for examination when the surgeon arrives and whatever he may be expected to need should be in readiness. The hemorrhage is usually con- trolled by packing the rectum with tampons saturated with an astringent solution or with vaseline. The articles required will be a good light, sterile gloves, wipes, sponges, dressings, forceps, a rectal speculum, a sterile solution, etc., for irrigating, and the tampons for packing. The dressings are held in place with a T binder. Pain is always severe and constant, because of the many nerves about the anus, and must be relieved. It makes the patient restless, prevents him from sleeping, and lowers his resistance. Opium suppositories are usually inserted directly after the operation, which relieve pain and keep the part at rest by limiting peristalsis. Hot moist dressings relieve inflamma- tion, swelling and pain. An ice-bag applied to the part gives great relief. Retention of Urine.—Pain is often caused or increased by retention of urine resulting from paralysis of the muscular wall of the bladder which is controlled by the same nerves which supply the rectum and anus. Retention should always be watched for and must be relieved either by voiding or catheter- ization. The Care of the Wound.—The wound must be kept at rest and absolutely clean. Fluid diet only is allowed and the bowels are kept closed for the first four days. After urination the parts should be carefully cleansed and a dry sterile dressing applied and held in place with a T binder. Dressings must be securely fastened to prevent displacement. The wound should be watched for signs of inflammation. A rise in temperature and an in- crease in pulse rate should suggest infection of the wound. Do not disturb the wound more than is absolutely necessary, as this predisposes to infection. On the fifth day, to soften fecal matter and cause a movement of the bowel without effort, one dram of compound licorice powder or one ounce of castor oil is usually given by mouth, followed later by an oil enema given through the tube inserted in the rectum at the time of the opera- tion. This tube is later expelled with the movement. Some- times a simple cleansing enema is given one hour after the oil enema. The parts are thoroughly cleansed and a fresh sterile dressing applied. Care and gentleness must be used in all treat- ments and dressings. The bowels are then kept open with daily movements, if necessary by an enema or mild laxative, followed by cleansing and dressings. Light diet is allowed with food leaving little residue. No straining of any kind should be al- lowed. When the patient sits up he should be given a rubber ring for comfort and to relieve pressure. 594 THE PRINCIPLES AND PRACTICE OF NURSING In an excision of the rectum, prolapse of the rectum, or a rectal abscess, the necessity for extreme care is even more im- portant. Where there is drainage the dressings should be changed frequently as the wet dressings make the patient very uncom- fortable and restless. Elevating the head of the bed promotes free drainage. Hot moist dressings also promote free drainage. The odor from sloughing tissues and from soiled dressings is always most distressing to the patient and is to be avoided by absolute cleanliness and frequent change of dressings. When practicable, the hot sitz bath removes odors and promotes drain- age, cleanliness and healing. In a prolapse of the rectum, the foot of the bed is elevated. In all cases the diet should be nutritious, easily digested, leav- ing little residue so that there will be little or no stool. OPERATIONS ON THE GALL BLADDER AND DUCTS Common operations on the gall bladder are: Cholecystotomy (incision of the gall bladder), usually for the purpose of drain- age; cholecystostomy, the formation of a fistula into the gall bladder for drainage; cholelithotomy, incision into the gall blad- der for the removal of stones; choledocholithotomy, incision of the common bile duct for the removal of gall stones; cholecystec- tomy, excision of the gall bladder. The chief factors to remember in the after-treatment are the danger of severe shock from the necessary handling of viscera in the upper abdomen; the danger of pneumonia from exposure and handling of the diaphragm and peritoneum of the upper abdomen; the danger from paresis of the stomach with dilatation and persistent vomiting following, resulting from the handling of the duodenum and pyloric region of the stomach; the danger of adhesions and later interference with the action of the stomach and small intestines; the danger of hemorrhage in jaundiced pa- tients—the presence of bile in the blood prevents it from clotting in the normal time; the necessity for adequate drainage and the unobstructed flow of bile; the irritating effect of bile on the wound and skin. The treatments following the operation may be a transfusion, infusion, or hypodermoclysis to relieve shock and ioss of blood. A hypodermoclysis, or saline by the Murphy-drip method, may be ordered to supply the tissues with fluid. The patient's position is important. He is usually propped up in bed to allow free drainage, to prevent pneumonia, to pre- vent pressure on the diaphragm and make breathing more com- fortable. The temperature reaction, etc., is usually not so great in this position. Extreme care must be used in the diet. Small amounts only of fluids are given. Lavage is given for persistent vomiting. When drainage is the object of the operation, it must be watched with extreme care. See that the drainage tube is in AFTER-TREATMENT IN SPECIAL OPERATIONS 595 the bottle and draining properly—note the amount and char- acter of the bile discharged. The discharge may consist only of mucus from the inflamed lining of the gall bladder instead of bile. Watch the stools to see if normal in color or not. If normal it shows that the inflammation or obstruction has sub- sided, but if "clay-colored" it shows the obstruction is still pres- ent. Watch the color of the patient and note whether he is jaundiced or not in order to see whether the formation and dis- charge of bile is normal or not. Where there is drainage, pro- tect the skin from the irritating effects of the bile. Drainage from the common bile duct is apt to be particularly irritating because of the probable presence of pancreatic juice. The dressings should be kept dry and the skin protected with an ointment such as zinc oxid. Some surgeons do not apply a dressing over the wound at all because "a warm poultice of bile and pancreatic juice favors the digestion of tissues." When no dressing is used over the wound a cradle is used to protect the wound from the bed clothing, etc., and a large absorbent pad is placed at the side so as to receive the discharge. The position of the patient is changed frequently to prevent the discharge from flowing over the same area constantly. The discharge on the dressing is said to be more profuse and annoying at night than in the day because when the patient is fed most of the bile formed in the liver is discharged into the intestines to aid in the digestion of the food. Some surgeons therefore feed the patients every three or four hours during the night. Even when the "open treatment" (that is, with no dressing over the wound dur- ing the day) is used, the surgeon usually applies a large dressing for the night, as many patients sleep better with the sensation of the bed clothes in contact with the body. OPERATIONS ON THE URINARY TRACT The principal operations performed are nephrectomy, excision of the kidney; nephrolithotomy, incision of the kidney for the removal of a calculus; nephrotomy, incision of the kidney as for the drainage of an abscess, etc., and prostatectomy, excision of the prostate gland (male reproductive system). The principal factors to remember in the after-treatment are the danger of uremia, pneumonia, hemorrhage, shock, and acidosis. The amount, character and analysis of the urine voided must be very carefully noted and recorded. The urine should be watched for the presence of blood. If the patient fails to void, catheterization is usually done to find out whether the anuria is due to retention or suppression. Headache, vomiting, dimness of vision, drowsiness, restlessness, and a high-tension, incom- pressible pulse, partial or complete loss of consciousness, con- vulsions, coma and death will follow if these symptoms are over- looked and the condition is allowed to go untreated. To prevent suppression, particular care must be taken to keep 596 THE PRINCIPLES AND PRACTICE OF NURSING the patient warm with extra blankets in order to prevent internal congestion, and to stimulate excretions of waste by the skin. To aid in the elimination of waste products, fluids are supplied to the tissues intravenously, by hypodermoclysis, or by proctoclysis, and hot fluids are given freely by mouth as soon as nausea ceases. Bicarbonate of soda or glucose solution is frequently added to the proctoclysis to combat acidosis. The bowels must be kept open. Saline cathartics are sometimes given for this pur- pose. Hot colon irrigations are often given to stimulate the kidneys, supply fluid and aid in the elimination. Drugs such as digitalis may be ordered to stimulate the kidneys and urotro- pin may be given as a urinary antiseptic. Benzoic acid or acid sodium phosphate is frequently given with urotropin because an acid medium is necessary to cause urotropin to break up, yield- ing formaldehyde, to which its antiseptic properties are due. Hot packs may be ordered if the kidneys show signs of failure. Pneumonia is one of the dangers to be particularly guarded against. The kidneys are high up in the abdomen, directly under the diaphragm, and the posterior lobes of the lungs. Par- ticular care must be taken after a prostatectomy, which is usually performed on old men as all old people are particularly susceptible to pneumonia. They must be kept warm with plenty of clothing and all exposure, chilling and drafts avoided. The patient is usually propped up in bed, and the surgeon orders a back-rest and allows the patient up in a chair as soon as pos- sible. The position should be changed frequently, but where drainage is desired the position must be such as to promote free drainage. The dressing should be watched for staining. Where there is drainage, the amount of urine on the dressings or discharged through the tube into a bottle should be noted. The rubber drainage tube should be watched to see that it does not collapse and that pressure, etc., does not interrupt the flow of urine. Soiled dressings should be changed. Urine retards the healing of a wound and forms a good culture medium for germs, and decomposed urine is very irritating. No strong antiseptics such as iodoform or bichlorid of mercury, etc., are ever used on the wound because of the danger of absorption and irritation of the kidney in elimination. Following a prostatectomy and similar operations on the urethra or bladder, the scrotum must be supported for the reasons already mentioned under a herniotomy. After a prostatectomy a patient is very uncomfortable, usually suffers from severe pain, and is apt to be very restless, excitable, and often delirious. Such patients require constant attention and very careful nursing. To prevent shock and hemorrhage the patient must have absolute rest. His general health is also extremely important. He must have rest, sleep, comfort, fresh air, and light but nour- ishing diet. AFTER-TREATMENT IN SPECIAL OPERATIONS 597 OPERATIONS ON THE FEMALE REPRODUCTIVE ORGANS Operations on the pelvic organs may be followed by shock, hemorrhage and retention of urine. The amount and character of the urine voided must be closely watched, not only because of the danger of retention of urine due to paralysis of the blad- der walls, but during the operation the bladder, or more fre- quently the ureters, may be injured. The ureters lie very close to the uterine artery and are occasionally accidentally ligatured or actually injured during the operation. The result would be very serious, if not fatal, if the condition were not recognized and the patient operated upon immediately to relieve it. Occa- sionally the rectum is accidentally injured. Watch for symptoms of cystitis, as this condition seems to develop more frequently after operations on the pelvic organs. Watch for symptoms of hemorrhage, either internal or exter- nal, on the vaginal dressing, particularly after a vaginal hys- terectomy. Watch the urine, when the patient voids, for the presence of blood. The patient may be bleeding and the re- moval of the dressing and the act of voiding may cause a severe hemorrhage. Be careful in giving and removing the bedpan to cause the patient as little exertion as possible. Note any vaginal discharge following operations on the uterus, etc. Following operations on the uterine ligaments to correct dis- placements (retroversion or retroflexion) of the uterus, the pa- tient is usually required to lie upon her side inclined toward her face in order to keep the uterus, by gravity, in the antiflexed and antiverted position. Lying on the back causes a strain on the internal sutures and ligaments holding the uterus in its new position. Following all operations, such as for ectopic gestation with rupture of the tube, in which the loss of blood has been large, the patient must have absolute rest and treatments to repair the loss of blood. The psychic effect of the removal of the uterus or ovaries is an extremely important factor in the after-treatment. The re- moval of the uterus or of both ovaries deprives tha patient of the possibility of having children. In many cases this has a very morbid, depressing effect on the mind which must be coun- teracted if possible. "The love of children and the maternal instinct is strong in every good woman and the thought of 'what might have been' is always a saddening one." The re- moval of the ovaries also brings nervous disorders, hot flushes, and other distressing symptoms of the menopause. This is counteracted by the administration of ovarian extract or extract of the corpus luteum. Vaginal dressings are necessary after such operations as a vaginal hysterectomy, curettage of the uterus, and a trachelor- rhaphy. They include the necessary changing of the dressing 598 THE PRINCIPLES AND PRACTICE OF NURSING following the use of the bedpan, the removal of packing, vaginal irrigation, and the removal of sutures. In all cases the dressing is a sterile procedure, observing the most strict aseptic pre- cautions. After the use of the bedpan the parts are thoroughly but gently cleansed, dried, and a sterile dressing applied, held se- curely in position by a T binder which must always be scrupu- lously clean, and so fastened as to prevent displacement. The removal of packing and sutures, wound dressings, and irrigations are dressings performed by the doctor. The instru- ments, etc., required will depend upon the dressing. The position of the patient must be both convenient for the doctor and com- fortable for the patient. Frequently the patient is placed on a special examining table. The patient must be warm. No un- necessary exposure should be allowed and the patient's feelings must be considered in every way. A nurse always remains throughout the dressing. The area surrounding the parts is draped with sterile sheets. There must be a separate receptacle for soiled dressings and packing, and another basin for soiled instruments. When an irrigation is required, a warm, dry, pro- tected douche pan is placed under the patient. It must not be so placed until the doctor is ready to begin the irrigation and must be removed immediately afterwards. PERINEORRHAPHY The perineum is sometimes torn during childbirth. A peri- neorrhaphy is an operation in which the lacerated perineum is sutured. The after-treatment, like that of any other wound, is ex- tremely important. Its care is the responsibility of the nurse. All strain on sutures, whether due to restless movements or to straining at stool, must be avoided. Sometimes it is necessary to bandage the thighs together. The sutures must be kept scrupulously clean and free from infection. Some surgeons re- quire the patient to be catheterized for the first three to five days to avoid contamination of the wound with urine. All dressings are carried out with strict aseptic precautions, as in treating an abdominal wound. After the use of the bedpan, the part is irrigated with boric acid solution and very gently sponged until quite clean. The parts are then dried gently. Dry sterile dressings are usually applied. Aristol (an antiseptic) or zinc oxid ointment is frequently used. Any symptoms of inflamma- tion—soreness, redness, swelling—in the wound should be noted and reported. Hot moist antiseptic dressings may be ordered in such cases. Dressings are held in place with a T binder. When vaginal douches are ordered following a perineorrhaphy, a soft rubber catheter or an irrigating tip instead of the usual douche nozzle should be used. The douche should coincide with one of the usual dressings so as not to disturb the wound more than is absolutely necessary. CHAPTER XXXV THE NURSING CARE IN ACCIDENTS AND EMERGENCIES When an accident occurs or an emergency arises, a nurse has often to proceed without a doctor. In order to do so, she must be able to recognize what has happened, think clearly, act promptly, know what to do, and how to do it. The accidents and emergencies which most commonly occur are injuries resulting in shock, hemorrhage, a wound, bruise, burn, sprain, dislocation or fracture. These will be discussed in the present chapter. SHOCK As some degree of shock almost always follows severe injuries, one of the first points to consider in the treatment of accidents is how to prevent the development of shock, and to treat it if present. The causes, symptoms, and treatment of shock have been discussed in a previous chapter. In shock following an acci- dent the only other factors to consider are the conditions under which an accident occurs—a crowd usually gathers around and the patient must usually be moved to a place of safety. Quiet, rest, fresh air, and warmth are essential. Only those necessary to assist should be allowed to remain. The patient should not be allowed to remain lying on a cold floor, in the cold, or in a draft, and he should not be allowed to exert himself by walking, standing or remaining in the sitting position long, but should be placed in the recumbent position, and external warmth applied. The extremities may be rubbed to increase body heat. Whatever stimulants are at hand—tea, hot coffee, small doses of whisky or brandy—may be given by mouth, or by rectum if the patient is unconscious. Strychnin, caffein, or atropin may be given by hypodermic, if available, unless hemorrhage is also present, or in accidents resulting in injury to the head. In handling the injured part care must be taken to avoid pain as this is always a powerful factor in producing shock. Shock may follow even slight accidents and its probability should always be remembered. Sometimes a slight nervousness and excitement may be the only symptoms. It does not always develop immediately after the injury but if precautions are not taken to prevent it, the patient may be completely prostrated later. Children, old people, alcoholics, anemic and debilitated 599 600 THE PRINCIPLES AND PRACTICE OF NURSING people are particularly susceptible to shock. Injuries to the chest and abdomen are almost invariably followed by severe shock. In all cases the pulse must be watched closely. Alcoholic patients must be watched for restlessness and sleeplessness as delirium tremens is very apt to develop. HEMORRHAGE Hemorrhage is the escape of blood from the vessels which occurs as the result of trauma, or disease. Varieties of Hemorrhage, or classification: I. According to Time: (a) A primary hemorrhage is one which occurs at the time of the injury. (b) An intermediate or recurrent hemorrhage is one which occurs in from 12 to 48 hours after. (c) A secondary hemorrhage is one which occurs after a few days—from two days up to the time of complete healing. II. According to the Cause: (a) Trauma. 1. An external hemorrhage is one in which the blood escapes from the skin or soft parts. 2. An internal or concealed hemorrhage is one in which the blood escapes into a body cavity. Examples would be a hemor- rhage into the pelvic cavity in injury to the pelvic viscera or in rupture of the Fallopian tubes; a hemorrhage into the stomach; hemothorax, and bleeding into the peritoneal cavity in typhoid fever. 3. A subcutaneous hemorrhage is one in which the bleeding is into the soft tissues beneath the unbroken skin. Examples of subcutaneous hemorrhage are a false aneurysm, that is, an extensive hemorrhage from an artery into the subcutaneous tissue forming a pulsating tumor; a hematoma, that is, an extensive hemorrhage from a vein forming a tumor which does not pul- sate; a contusion or bruise in which bleeding occurs from many small blood-vessels; ecchymoses or "black and blue marks" are hemorrhages too small to form a tumor. (b) Disease. 1. In scurvy—bleeding from the gums. 2. In typhoid—bleeding from ulcers in the intestines. 3. Epistaxis—bleeding from the nose due to ulceration or congestion of the mucous membranes. 4. Hemoptysis—bleeding from the lungs in tuberculosis. 5. Hematemesis—bleeding from the stomach in ulcers or carcinoma, etc. 6. Melena—bleeding from the intestines from ulceration, con- gestion, or new growths. 7. Hematuria—bleeding from the urinary tract in diseases of the kidneys, ureters, bladder, prostate, or urethra, and from calculi or new growths. NURSING CARE IN ACCIDENTS AND EMERGENCIES 601 8. Cerebral hemorrhage (apoplexy)—hemorrhage in the brain from disease of the blood-vessels (endarteritis). 9. Purpura and petechias are very small hemorrhages (pete- chias are pin points) into the skin and mucous membranes which do not disappear on pressure. At first they are bright red, become darker and finally fade to brownish stains (due to the disintegration of the red cells and hemoglobin freeing hema- tin, a brownish pigment). They occur in infectious diseases— measles, scarlet fever, small-pox, typhus fever, in pyemia, sep- ticemia, and leukemia and in purpura hemorrhagica in which there may also be epistaxis, hematuria, etc. 10. Hemophilia is an hereditary disease which occurs almost exclusively in men, but is transmitted along the female line, that is, from mother to son. Men suffering from this disease are called bleeders. Their blood fails to clot so that bleeding from a slight wound or from the extraction of a tooth may be impossible to control and the patient may bleed to death. The treatment is administration of calcium lactate which aids the clotting of the blood. III. According to the Source: (a) Arterial hemorrhage or bleeding from an artery is most dangerous because difficult to control. It may be recognized by (1) the bright red color (oxyhemoglobin) ; (2) the blood escapes in spurts occurring with the heart beat or pulse; (3) in an ex- tremity the pulse below may be obliterated and pressure above the wound (between it and the heart) controls it. (b) Venous hemorrhage or bleeding from a vein. The blood is darker in color, due to the loss of oxygen. It flows steadily and bleeding is easily controlled. The blood pressure is very low in the veins; the walls are less elastic and muscular than the arteries so do not contract, but collapse when cut. (c) Capillary hemorrhage in which there is a general oozing of blood from the surface. It neither spurts nor flows steadily, but wells up in the wound and the surface seems to "weep." In a deep wound the blood trickles down over the surface and gradually fills it up from the bottom. Hemorrhage may occur from all three sources together. IV. According to the Severity and Danger: Hemorrhage may be slight, severe, or profuse, according to the extent of the injury, the size and number of vessels cut, the amount of blood and rapidity with which it is lost. A severe hemorrhage occurs from a large artery or vein and is always accompanied by shock. A sudden loss is much more dangerous than a gradual loss, because in the former the heart, blood- vessels and nerve centers are taken unawares and have no time to adjust themselves. A gradual loss, however, as from hemor- rhoids, may cause a very severe anemia. A profuse hemorrhage occurs from large and important vessels so rapidly and in such quantities it is hard to find the source and control it. It is always accompanied by severe shock and is usually rapidly fatal. 602 THE PRINCIPLES AND PRACTICE OF NURSING Hemorrhages are more serious in children, in the aged, in alco- holics, and in those suffering from diseases of the kidney. The symptoms of an internal hemorrhage and the systemic symptoms of a hemorrhage either external or internal have already been discussed in Chapter XXXII. Nature's Method of Reacting to the Injury and Loss of Blood.—When a small vessel is cut, its muscular walls contract, Temporal Subclavian Axillary Brachial Palmar arch Femoral Popliteal Anterior tibial Posterior tibial Facial External carotid Common carotid Fig. 134.—The Relation of the Principal Arteries to the Bones. The arrows indicate the points where pressure may best be applied. (From Morrow's "Immediate Care of the Injured," W. B. Saunders Co., Pub- lishers.) NURSING CARE IN ACCIDENTS AND EMERGENCIES 603 making its lumen smaller, and at the same time it retracts or shrinks back within its outer elastic sheath (much as a worm retracts into the ground when irritated) which then partially or completely closes over the opening. The blood, meeting this re- sistance, and coming in contact with air, soon begins to coagu- late, forming clots around the opening and extending into the lumen, so that bleeding is checked before a serious loss occurs. If this were not so the merest scratch causing a hemorrhage would be fatal if untreated. Clotting occurs very quickly in these small vessels, especially the veins, because their walls collapse more readily than the arteries and prevent a serious loss of blood. When large blood vessels are injured, clots cannot form at first because of the force of the blood current. As blood continues to escape, however, the volume is so depleted the brain (and other organs likewise), with its vital centers, becomes anemic. The patient faints; the vaso- motor center is paralyzed; the blood pressure is lowered; the less- ened volume of blood in the vessels also weakens the heart and lowers the blood pressure. A hemorrhage also tends to increase the coagulability of the remaining blood so that, as the force of the blood current is reduced, the blood is able to clot and finally plug up the opening before death occurs. (In wounds of the largest vessels, blood is lost so rapidly death occurs before Nature has a chance to react or recuperate.) Later the blood-forming organs manufacture and deliver to the blood an increased number of cells to make up for those lost. Local Treatment of Hemorrhage.—Hemorrhage may be con- trolled by (1) pressure; (2) position; (3) extreme heat or cold; (4) astringents or styptics; (5) ligation; (6) torsion; (7) sutures; (8) the cautery. Pressure may be made with the fingers (digital pressure), a tourniquet, compresses or packing and a tight bandage. The bleeding must be controlled by whatever means lies in one's power in order to prevent the patient from bleeding to death. Pressure with the fingers along the course of the bleeding vessel will control a hemorrhage temporarily even from a large vessel. A nurse should know exactly where and how pressure may be made on large vessels such as the facial, carotid, subclavian, axillary, brachial, and femoral arteries. She should feel on her- self where each artery approaches the surface and where it lies against a bone, that is, where its pulse may be most easily felt and compressed. Bleeding from the forearm can only be checked by pressure on the vessels in front of the elbow or on the brachial artery because the radial and ulnar arteries are too deeply im- bedded in the tissues to be easily compressible. Their branches also anastomose freely. The same is true of bleeding from the lower leg. In bleeding from an artery, pressure must be made above the wound, that is, between it and the heart. In bleeding from a vein 604 THE PRINCIPLES AND PRACTICE OF NURSING digital pressure must be made below the bleeding point, that is, between it and the periphery. Also all tight constricting bands (tight clothing or elastic garters, etc.) between the bleeding point and the heart must be removed to allow the blood to return by the deep veins. This will prevent or relieve congestion (which always increases venous hemorrhage) and lessen the bleeding from the superficial veins, usually the ones injured. The Tourniquet.—Fingers soon tire so other means must be substituted. One of the most successful means of controlling bleeding from a large artery in an extremity is by applying a tourniquet above the bleeding point. The specially constructed tourniquets are made either of elastic rubber or of heavily braided material as in the army tourniquet. Improvised tourniquets may be used—rubber tubing, a folded handkerchief, a necktie, or leather strap, etc. In all cases the tourniquet must be wide enough not to cut the skin and pressure must never be made on nerve trunks. A hard firm compress is placed over the line of the artery (where digital pressure is made) and the tourniquet is tightened around it. It must be applied tightly enough to control the hemorrhage, if necessary tightly enough to obliterate the pulse. It is never left on longer than necessary because pro- longed pressure causes severe pain and may cause severe injury to the tissues and nerves and may even cause gangrene. It must be left on, however, until the services of a surgeon are secured, which should be done as soon as possible. If this cannot be done within an hour usually a clot has sufficiently formed to allow the tourniquet to be loosened (but not removed) after a dressing and tight bandage have been applied to the wound. Sterile gauze packing in the wound or sterile compresses held by a tight bandage will usually control hemorrhage from a vein or capillaries. Position.—Elevation of an extremity is one of the simplest and most quickly applied remedies. Elevation alone or com- bined with other temporary remedies is usually successful and may save the life of a patient. Hyperflexion at the elbow or knee joints, that is, placing a pad in the bend and flexing the forearm against the upper firm or the lower leg against the thigh and maintaining the position with a tight bandage will usually control hemorrhage from an artery in the forearm or leg. This combines position and pressure. The head, or the head of the bed, is elevated in epistaxis or cerebral hemorrhage. The foot of the bed, or the buttocks, is elevated in bleeding from the pel- vis, etc. The application of heat or cold will often check venous or capillary hemorrhages. When hot water is used it must be very hot, 120° to 140° F., to contract the blood vessels as warm water causes further dilatation and bleeding. Heat also hastens clot- ting by coagulating the albumin of the blood and tissues. A hot vaginal or intra-uterine douche is one of the methods used to control bleeding from the uterus. NURSING CARE IN ACCIDENTS AND EMERGENCIES 605 An ice-bag or ice compresses will often check capillary hem- orrhages and will give great relief, check bleeding and prevent discoloration (black and blue marks) in subcutaneous hemor- rhages such as contusions. Following a tonsillectomy, it is cus- tomary to slap the face with towels wrung out of ice water. The stimulation of the nerve endings in the skin due to the cold and slapping contracts the surface blood vessels and reflexly causes the contraction of the deeper vessels. An ice-bag is also applied to the throat. The prolonged use of ice, however, may be dan- gerous as it checks the circulation, lessens the supply of healing blood to the part and may cause gangrene especially in exten- sive bruises or in devitalized tissues. Children and old people do not stand cold well for extensive periods. Astringents and Styptics.—Adrenalin checks bleeding by con- tracting the arteries. It is used both internally and externally. The vegetable and metallic astringents such as alum, tannic acid, acetic acid, silver nitrate, ferric chlorid and ferric sulphate, etc., check bleeding by precipitating the proteins, contracting the tis- sues and coagulating the blood. They are sometimes used to check capillary bleeding. Acetic acid is often added to a hot douche. Ligation is exposing the bleeding vessel and tying a ligature around it. Torsion is arresting hemorrhage by twisting the divided end of an artery which causes rupture and inversion of its inner coats. Suturing is arresting hemorrhage by suturing wounds in large vessels too large to be closed by ligature. The cautery is used to check bleeding from the cut surface of bone, of inflammatory tissue and in surgical operations such as hemorrhoids. Systemic Treatment of Hemorrhage.—If the injury has been severe the patient will suffer from shock. If a considerable amount of blood has been lost he will suffer from this loss also and the effect and treatment will be much the same. In shock no blood is actually lost, but as it stagnates in the large veins the heart is without blood to supply the tissues so that the brain and heart muscles, etc., smother for want of oxygen and starve for want of food. In hemorrhage blood is actually lost, the effect on the brain and heart is the same and, after the hemorrhage is controlled, the treatment is much the same. Even while control- ling the hemorrhage the treatment for shock should be remem- bered and begun at once. The patient should be kept quiet, in the recumbent position, the clothing about the chest loosened and the body warmth increased. For the loss of blood the patient should have absolute quiet and rest in bed to lessen the work of the heart and the demands of the tissues. The head should be lowered, the trunk and ex- tremities elevated to cause more blood to gravitate to the brain to supply the vital centers. To give the heart more blood to pump and keep blood where it is vitally needed, the limbs may 606 l'HE PRINCIPLES AND PRACTICE OF NURSING be temporarily deprived of blood by elevating them and bandag- ing from the fingers and toes toward the heart. To increase the volume of blood direct transfusions or infusions of normal saline solution may be given. Heat may be applied to the extremities and hot fluids by mouth or by rectum may be given. Later to aid Nature repair the loss, rest, fresh air, sunlight, nutritious food and tonics (iron and arsenic) to increase the hemoglobin and stimulate the blood-forming organs are valuable. HEMORRHAGES FROM SPECIAL REGIONS Epistaxis or Bleeding from the Nose.—Epistaxis is a capillary hemorrhage from a deeply congested mucous membrane. It may be profuse and long continued. The great vascularity of the nose accounts for the frequency of epistaxis. The blood supply is very free and is derived from the ophthalmic, facial and internal maxillary arteries. The mu- cous membrane over the turbinate bones is thick and vascular, the thickness being largely due to the abundant submucous plexus of veins. Over the inferior turbinate bone the veins form a kind of "cavernous or erectile tissue" (Woolsey) which may swell up rapidly from engorgement of the veins so as to come in contact with the septum. This tissue shrinks very rapidly on the appli- cation of astringents. The great vascularity is for the purpose of warming the air inspired in respiration. Causes of Epistaxis: 1. Local causes.—Traumatism, ulceration (frequent on the sep- tum), foreign bodies, new growths, picking and scratching with the fingers. 2. Constitutional Causes.—Plethora, hemophilia, chronic anemia, preceding certain fevers especially typhoid fever, venous congestion occurring in cardiac or pulmonary diseases or cerebral congestion, puberty in delicate children especially those with a rheumatic tendency. There may be an hereditary tendency to it. Epistaxis may occur during sleep, the blood swallowed later being vomited, and so confused with hematemesis; or the blood may be coughed up and so confused with hemoptysis. Treatment.—The patient's head should be kept erect, to aid the venous return. He should not bend over a basin or wear a tight collar. The clothes should be loosened. Raising the arms above the head will lessen the blood supply to the nose. The arterial blood is lessened, because most of the blood will take the easiest pathway straight up the brachial arteries rather than through the tortuous arteries of the face. The venous blood is lessened, because this position expands the chest. We instinc- tively assume this position when we "stretch" and take a deep breath, or yawn, after close confinement. This chest expansion lessens the pressure on the large venous trunks, with resulting aspiration of the cervical veins. The blood also tends to clot and spontaneously check the bleed- ing. The patient should be warned not to blow his nose or in NURSING CARE IN ACCIDENTS AND EMERGENCIES 607 any way loosen the clots. Ice or ice compresses should be ap- plied to the forehead, the bridge of the nose, and back of the neck. Ice may be pressed against the nose. Very hot or cold water may be injected into the nostrils. Compression may be made on the facial artery by pressure on the superior maxilla near the nose on the bleeding side. Spunk may be inserted in the bleeding nostril. When moist, it swells and in this way local pressure is applied which helps to check the bleeding. The anterior nares may be packed with sterile gauze or cotton. Astringents may be injected, or dropped into the nostrils, or cotton, moistened with astringents, may be pressed into the nostrils. Adrenalin chlorid 1:1000 solution, compound tincture of benzoin, Monsil's solution (Ferri subsulphas), peroxid of hydrogen, or hamamelis, etc., may be used. Ergot may be given internally when bleeding continues. A hot foot-bath may check bleeding by dilating the blood vessels in the extremities and drawing blood away from the head. When considerable blood has been lost, this may cause fainting, unless given in the recumbent position. When the above means are unsuccessful the posterior nares must be packed. Hematemesis, Gastrorrhagia, or Bleeding from the Stomach. —The vomiting of blood is not always a sign of bleeding from the stomach because blood from the nose, throat, or lungs may be swallowed and vomited later. The blood supply to the walls of the stomach is very free; the gastric, hepatic, and splenic arteries run along both curvatures, branches from which anastomose freely. "If the larger trunk vessels are concerned in a gastric ulcer and become adherent to the stomach wall and finally eroded, serious hemorrhage into the stomach may result." "The veins empty into the portal vein either directly or through the splenic and superior mesenteric. Hence the varicose gastric veins and the congestion of the stomach, with hemorrhage into it, in cirrhosis of the liver, or cardiac disease accompanied by portal obstruction." When red blood cells remain in the stomach for a short time, they are disintegrated or digested by the action of the gastric juice, setting free the hemoglobin. Hemoglobin is in turn disin- tegrated-by the acid (hydrochloric acid) medium, forming globin (a protein) and hematin (a brown pigment). The same results occur in the intestines, as either a strong acid or alkaline medium disintegrates hemoglobin. This accounts for the clotted, dark brown or "coffee ground" vomitus and also for the "tarry" stool when the hemorrhage has occurred some time before. Blood from the stomach will have an acid reaction. Causes of Hematemesis: 1. Local.— (a) Cancer, ulcer, diseases of the blood-vessels (miliary aneurysms and varicose veins), acute congestion, and following operations on the abdomen. (b) Passive congestion, due to obstruction of the portal sys- 608 THE PRINCIPLES AND PRACTICE OF NURSING tem as in cirrhosis of the liver, thrombus in the portal vein, an enlarged spleen, pressure on the portal vein from without by tumors. (c) Traumatism—wounds, corrosive poisons, etc. 2. Constitutional.—Hemophilia and severe anemia. Treatment. The patient must be put to bed in the recumbent position and kept absolutely quiet. Morphin is usually given to put the patient and the stomach absolutely at rest, and to aid in the formation of a clot. Nothing should be given by mouth ex- cept small quantities of cracked ice. Astringents such as adrena- lin, or tannic acid are occasionally given by mouth. Cold com- presses, an ice-bag or the ice-coil should be applied to the epi- gastrium. Ergotin is sometimes given hypodermically. No stim- ulants are given because of the danger of increasing the hemorrhage. When the loss of blood has been great, syncope may result and must be treated. A direct transfusion may be given or an infu- sion of normal saline solution. The extremities may be bandaged toward the heart. The later treatment consists in tonics and a carefully regulated diet. Hemoptysis—the Coughing or Spitting of Blood.—Causes. 1. Pulmonary tuberculosis, from rupture of a blood vessel. 2. Diseases of the lungs—pneumonia, cancer, abscess, gan- grene, etc., and ulceration of the bronchi, trachea, or larynx. 3. Certain diseases of the heart, particularly mitral lesions which cause a damming back of blood in the left auricle, next into the pulmonary vessels, causing marked pulmo- nary congestion. 4. Aneurysm and erosion of a large blood vessel, which may cause a fatal hemorrhage. The following is a table, taken from Osier, to differentiate between hemoptysis and hematemesis: HEMATEMESIS 1. Previous history points to gastric, hepatic, or splenic disease. 2. The blood is brought up by vomiting, prior to which the patient may experience a feeling of giddiness or faint- ness. HEMOPTYSIS 1. Cough or signs of some pul- monary or cardiac disease precedes, in many cases, the hemorrhage. 2. The blood is coughed up, and is usually preceded by a sensation of tickling in the throat. If vomiting oc- curs, it follows the cough- ing. NURSING CARE IN ACCIDENTS AND EMERGENCIES 609 3. The blood is usually clotted, 3. The blood is frothy, bright mixed with particles of red in color, alkaline in re- food, and has an acid reac- action. If clotted, rarely in tion. It may be dark, gru- such large coagula, and mous, and fluid. muco-pus may be mixed with it. 4. Subsequent to the attack 4. The cough persists, physi- the patient passes tarry cal signs of local disease in stools, and signs of disease the chest may usually be of the abdominal viscera detected and the sputa may may be detected. be blood-stained for many days. _ Treatment.—Complete rest in bed and absolute quiet are essen- tial. The patient is usually very much alarmed and very much depressed. He should be reassured, his mind and body both put at rest. Death is rarely due to hemoptysis from a congested lung. (Osier.) Morphin is usually given to quiet the patient. To lessen the heart-beats and lower the blood-pressure, a hypo- dermic of nitroglycerin, gr. 1/100, or an inhalation of amyl nitrate (5 minims) is frequently ordered. The patient should be turned on the affected side, if known, as the blood is then less apt to enter the unaffected lung. How- ever, if the patient wants to sit up and can breathe better and is less anxious or alarmed when sitting up, it is better to allow him to do so. To lessen the nervous excitement and the distressing cough, chloral and bromids are frequently given by mouth or by rectum. No stimulants should be given or allowed in the food or drink. Ice may be given to suck. An ice-bag is sometimes applied over the sternum or over the part where the bleeding is thought to be. When the hemorrhage continues, salts are sometimes given to cause purging in order to lower the blood-pressure. When the hemorrhage is very severe, the head must be lowered to keep the blood in the vital parts. The extremities may be bandaged. When food is permitted, it should be very light. Hemorrhage from the Uterus.—The blood supply to the walls of the uterus is very free, coming from both the uterine and ovarian arteries, branches of which anastomose freely with each other so that bleeding may be profuse. The causes may be (1) inflammation of the uterus, ovaries or Fallopian tubes; (2) tumors; (3) foreign bodies; (4) displace- ments; (5) systemic disorders and visceral diseases such as dis- eases of the heart. Menorrhagia is a profuse or prolonged menstrual flow. Metrorrhagia is loss of blood in the intervals between men- struation. Any irregular bleeding from the uterus or unusually profuse menstrual flow, particularly after the age of thirty-five, should be reported to a surgeon without delay. It may possibly 610 THE PRINCIPLES AND PRACTICE OF NURSING be due to carcinoma in which the only hope of cure is in an early diagnosis and surgical interference. If such a condition is brought to the attention of a nurse she should advise that person, with- out alarming her unnecessarily, to consult a surgeon. A post-partum hemorrhage is one occurring after child-birth or a miscarriage. Treatment.—This depends upon the cause. In all cases the patient should be put to bed and kept very quiet. The buttocks should be elevated and an ice-bag applied to the lower abdomen. Ergot may be given internally. Hot vaginal or intrauterine douches (118° to 120° F.) are usually given with or without astringents. Vaginal tampons or uterine tampons are frequently inserted to check bleeding by pressure. In giving douches or in packing the vagina or uterus everything must be sterile. An intrauterine douche or packing the uterus are procedures never attempted by a nurse except as a last resort when all other meas- ures have failed and only when impossible to secure the services of a doctor. The surgical treatment consists in the removal of the causes such as tumors, foreign bodies or displacements, etc., by opera- tive procedure. The systemic treatment consists in rest and gen- eral hygienic measures and the treatment of the systemic disorder. The treatment for a post-partum hemorrhage is discussed in text-books on obstetrics. ACCIDENTAL WOUNDS Accidental wounds may be incised, stab, punctured, lacerated, contused, or poisoned wounds. Incised wounds are caused by a sharp, cutting instrument, such as a razor, which severs the tissues causing them to gape open. Stab wounds are caused by a sharp, cutting pointed instrument such as a dagger or knife. Punctured wounds are made by a sharp, narrow, pointed in- strument such as a needle, splinter of wood or a nail. A rusty nail is more dangerous because being rough it injures the tissues more and also holds more dirt and bacteria. Gunshot wounds are also punctured wounds. . A contused wound is made by a blunt instrument. The skin is ruptured, crushed or split and the tissues around are bruised. A lacerated wound is one in which the tissues are torn apart— the edges are roughened and jagged and there is more or less contusion around it. Examples are, the bite of an animal, torn knuckles caused by striking the mouth and teeth, a hook drawn through the tissues, and wounds caused by machinery. Poisoned wounds may be caused by the bites of poisonous snakes or spiders, a "mad" dog, and insect bites and stings. Dangerous Effects of Accidental Wounds.— (1) Deeper structures such as tendons, muscles, nerves and large blood ves- NURSING CARE IN ACCIDENTS AND EMERGENCIES 611 sels may be injured especially in incised and stab wounds. Periph- eral nerves may be cut or crushed or may later be surrounded by dense scar tissue during the healing process. In either case they will fail to carry messages and degeneration of the nerve will quickly follow. Symptoms of paralysis or loss of sensation should always be watched for because repair may be possible if attended to immediately but if not the resulting deformity and loss of function will be permanent. Trophic nerves which govern the nutrition of the tissues may be injured. The muscles will lose their tone, become flaccid and waste away from lack of nutrition. Stab wounds may also injure vital organs and hollow organs may be punctured so that their infected contents are allowed to escape. 2. Hemorrhage is apt to be severe especially in incised and stab wounds. In punctured wounds the hemorrhage may be slight because the blood vessels are pushed ahead or aside. In a lacerated wound also, the blood clots more easily in the roughened irregular tissue and torn vessels tend to contract so are not so apt to bleed. 3. Shock may be severe especially in wounds to the chest, ab- domen, skull or large blood vessels. 4. Infection by pyogenic organisms or the tetanus bacillus may occur from dirt, clothing, powder, or other foreign body carried into the wound. (Slight wounds, even a pin-prick, are often the most serious because so apt to be neglected.) Foreign bodies always help bacteria to gain a foothold. No matter how rigid the aseptic technique, leaving behind infected material or tis- sues dead, badly injured, constricted and poorly nourished so that they are incapable of surviving always results in infection. Punctured wounds are particularly dangerous because of the depth of the wound and because the tissues contract after the passage of the instrument. This closes the mouth of the wound and allows no drainage or entrance of air. The tetanus bacillus thrives in the absence of air and in the presence of pyogenic organisms which use up the air. Infection is more apt to occur in the old or in otherwise weak- ened individuals. Treatment of Wounds.—The first-aid treatment is to stop bleeding, relieve or prevent shock, keep the wound clean and absolutely at rest. If available, iodin and a sterile dressing should be applied and, if severe, a splint or sling to keep the part at rest. Expert treatment by a surgeon should be obtained as soon as possible especially in wounds about the face to avoid deformity from scar formation. Where this is impossible for hours or days, further steps must be taken to cleanse the wound. The operator should scrub his hands in the usual way for a sterile dressing. The wound should be covered with sterile gauze and the area around it should be shaved if necessary and cleansed with tincture of green soap, sterile water and an antiseptic solu- tion. The wound itself should then be gently irrigated with an 612 THE PRINCIPLES AND PRACTICE OF NURSING antiseptic solution such as peroxid of hydrogen 1 to 3 and gently cleansed. All foreign matter should be removed. An instru- ment such as a needle should be examined to see if intact. A fish-hook in a wound is very painful and difficult to remove. Pushing it on through the tissues is often the only way. In all cases extreme gentleness must be used to avoid pain, shock, bleeding or bruising. All punctured wounds should be disin- fected thoroughly and kept open to let in the air. The surgeon will incise the wound opening it freely. Even slight wounds or burns caused by powder from toy pistols or fireworks and wounds contaminated with dirt, etc., from around stables are particu- larly liable to infection with the tetanus bacillus. A prophy- lactic dose of tetanus antitoxin should always be given immedi- ately. Lacerated and contused wounds are always left open for drainage. They are apt to become infected which may result in sloughing and, in severe cases, in gangrene. Hot antiseptic dress- ings are frequently used. Treatment for Poisoned Wounds.—Snake bites if poisonous cause pain, swelling and discoloration within a few minutes— blood poisoning, prostration and collapse may follow very quickly. The treatment is to prevent the poison from entering the general circulation and to treat for shock. Several tourni- quets are applied at different levels, the wound is freely incised, and bleeding is encouraged—wet cupping is sometimes used for this purpose. The wound may be swabbed with pure carbolic or cauterized. It should never be sucked as a slight abrasion on the lip would allow absorption of the poison. Complete rest, external heat and stimulants are necessary to counteract the shock. The tourniquets are removed one at a time (the one nearest the body first) if no symptoms of general poisoning appear. Poisonous bites from spiders are treated in the same way. The poison from stings of bees or wasps, etc., is acid and may, therefore, best be treated by alkaline solutions such as ammonia water, bicarbonate of soda, soap and water or a paste made of baking soda. The sting if left in should first be removed. This can be done by pressing firmly on the tissues around the wound with a round hollow object such as a key. Cold or hot com- presses moistened with an alkaline solution may be applied—hot applications are frequently more soothing. Shock may be severe when stings are caused by a swarm of bees. Bromids and mor- phin are given to relieve pain and nervousness. When the bites result in severe itching a weak solution of car- bolic acid relieves it due to its anesthetic effect on nerve endings. Hydrophobia or rabies is caused by the bite of a rabid animal, usually a dog. The virus causing the disease is in the dog's saliva which may transmit the disease to man through an abra- sion or any open wound, not necessarily from being bitten. The symptoms, in man, develop in from fourteen days to seven months after being bitten or otherwise infected. The time de- NURSING CARE IN ACCIDENTS AND EMERGENCIES 613 pends upon the amount of virus introduced, the point of inocu- lation and the susceptibility of the individual. When the bite is made through the clothing the saliva may be to a large extent removed. As the disease attacks the nervous system, when the bite occurs in tissues richly supplied with nerves, as in the face, the symptoms develop rapidly. The symptoms are headache, pain in the wound extending along the nerves, irritability, rest- lessness, sleeplessness, difficulty in breathing and swallowing due to spasmodic contractions of muscles and a marked increase in the flow of saliva. Convulsions usually follow. Death usually follows on the third or fourth day after the symptoms appear. When the symptoms have developed the disease is invariably fatal. Prevention of the disease is therefore of the greatest importance. Treatment.—A tourniquet is applied above the wound, if on an extremity, to prevent the poison entering the general circula- tion. The wound should be incised and opened freely. Bleed- ing is encouraged. It is then cleansed with antiseptics and hot antiseptic dressings are applied. If the animal is known to be rabid the Pasteur treatment should be given immediately. This consists in the injection of a specially prepared, standardized dose of an emulsion of the spinal cord of rabbits which have been treated with the virus. The emulsion is given subcutaneously in a series of twenty-five inoc- ulations. It stimulates the body to produce specific antibodes and thus renders the poison introduced in the saliva harmless. The treatment is very costly. After the symptoms have de- veloped the treatment is unavailing. The animal which did the biting should, if possible be kept alive and under expert observation in order to determine whether rabid or not. Animals, in hot weather, may appear "mad" when suffering from heat-stroke. If the animal has been killed, the body should be sent to a laboratory where the brain may be examined. The presence of certain round or angular bodies found within the nerve cells or their processes is accepted as diagnostic of the disease. CONTUSIONS A contusion is a bruise caused by a blunt force such as a kick, blow or crushing injury. There is no wound in the skin but a subcutaneous laceration with stretching and tearing of many minute blood vessels. Contusions are often associated with wounds and other in- juries. Head injuries are always dangerous and should be treated for fracture oAhe skull. Injuries to the chest are usually fol- lowed by severe shock which may be profound. A blow to the pit of the stomach spoken of as a "blow to the solar plexus" may cause instant death—for this reason "hitting below the belt" is prohibited in all sports such as boxing, etc. The danger of inter- 614 THE PRINCIPLES AND PRACTICE OF NURSING nal injury is also very great in blows, etc., on the abdomen and symptoms of such an injury should always be watched for. When a blow is expected the body instinctively protects itself by contracting the abdominal muscles making them rigid and board- like in order to protect the internal organs—the abdominal muscles would then be bruised or ruptured. When the blow is unexpected this protection is lacking so that intestines, kidneys, spleen or liver may be ruptured with no external evidence of injury on the surface. Rupture of the kidney, spleen or liver which are richly supplied with blood may result in a severe or fatal hemorrhage. Symptoms of peritonitis, internal hemorrhage, suppression of urine and blood in the urine or stools must be watched for. A fracture of a bone may also occur without ex- ternal signs. The symptoms of a contusion are pain, swelling, heat, dis- coloration and loss of function. The part is first red, then as the blood stagnates, blue-black, changing to violet, green, brown and yellow as the hemoglobin is gradually decomposed and the products finally reabsorbed. The blood works its way slowly to the skin. The discoloration may appear within a few hours or not for hours or days depending upon the blood supply of the part and the depth of the injured vessel. Where the tissue is loose as in the eyelids a "black eye" develops almost immedi- ately, whereas on the thighs or buttocks the thick muscles and dense fascia may prevent its appearance for days when the cause of the bruise may be entirely forgotten. When bleeding occurs from a large vessel forming a circum- scribed collection of blood enclosed by the tissue, it is called a hematoma—a blood tumor. The treatment consists in the local treatment to control the bleeding and restore the vitality of the part and the treatment for shock. The local treatment depends somewhat upon its ex- tent—rest, elevation where possible and applications of heat or cold are used. A splint may be used to secure rest. Cold com- presses may be used in the early stages and when the bruise is not extensive. Evaporating lotions such as lead and opium are cooling and give great relief when left uncovered to allow for evaporation. Wet dressings of lead and opium are also used. They are mildly antiseptic, astringent and soothing. Wet dress- ings of aluminium acetate are sometimes used. Aluminium ace- tate is mildly astringent and antiseptic. Magnesium sulphate solution acts as an anesthetic and re- lieves pain. An ice-bag as an application of cold must be used with extreme care. Its weight causes discomfort and the intense cold may cause gangrene when the tissues are badly injured and thus vitality lowered. All extensive bruises are best treated by hot antiseptic solutions. The danger of infection in the weakened tissue should be kept in mind. After cold applications have controlled the bleeding, they are no longer desirable. The part should be bandaged with even NURSING CARE IN ACCIDENTS AND EMERGENCIES 615 pressure and heat applied to aid absorption and restore the vitality of the part. Massage may be used later to restore the vitality. It should never be used soon after severe bruises be- cause of the danger of embolism. BURNS AND SCALDS Burns and scalds are caused by the exposure of the body to a very high temperature of either dry or moist heat. Burns are caused by dry heat—a flame, hot air, hot solids, electricity, X-Ray or radium—and by the action of corrosive poisons. Scalds are caused by moist heat—hot water and other fluids, steam or vapors. The effects produced on the tissues by burns and scalds are the same. Burns may be classified into three degrees according to the depth of the injury:—1, simple reddening of the skin; 2, der- matitis with the formation of blisters; 3, actual charring, roast- ing and destruction of tissues. This may involve the superficial layer only or both superficial and true skin, or the skin, sub- cutaneous tissue, and muscle. The symptoms are both local and constitutional and vary with the extent and location of the injury. The local symptoms are heat, redness, smarting, tenderness, sometimes excruciating pain, swelling, and loss of function. There may be blisters or sloughing of the tissues. In scalds the skin is white, thrown into rugae and the epidermis may be detached. Scalds are usually more extensive than burns because absorption by the clothing tends to diffuse the fluid over a larger area. Superficial burns are apt to be more painful than deep burns because burns involv- ing the upper layers of skin only will leave the ends of the nerves exposed whereas when all the layers are destroyed, the nerves are destroyed with them. The constitutional symptoms vary with the age and condition of the patient, the extent and location of the injury and the amount of tissue destruction. They are more marked in burns of the chest and abdomen than of the extremities and are greater in children. Children, old people and alcoholics stand burns badly. The symptoms are the symptoms of shock, of toxemia, of meningeal irritation and congestion, inflammation or congestion of internal organs—the liver, kidneys, lungs, brain or intestines —and of acute nephritis. Shock is present in nearly all burns. It depends more upon the extent and location than the depth of the burn. An extensive, superficial burn is much more serious than a deep burn of limited area. A burn involving an area equal to one-third of the body surface is usually fatal. Shock is more apt to be fatal in burns of the chest or abdomen and in children, old people and al- coholics. Toxemia is due to the absorption of toxic products from the dead tissues. Later during the period of suppuration the toxemia 616 THE PRINCIPLES AND PRACTICE OF NURSING will be caused by septic absorption. The symptoms are a high temperature, extreme thirst, weak, rapid pulse, low blood-pres- sure, vomiting and diarrhea. There may be delirium or stupor and finally convulsions or coma and death. The symptoms of meningeal irritation and congestion are head- ache, restlessness, delirium and coma. Inflammation and congestion of internal organs may be very se- vere and are frequently fatal. They may result from interference with the functions of the skin, the absorption of toxic products, the increased work thrown upon the liver (which acts as a detoxi- fying agent changing toxic products into non-irritating sub- stances) and upon the kidneys and other organs of elimination. It may be the reflex effect of the extreme heat on the nerves in the skin, which causes a contraction of the blood vessels in the skin with resulting congestion of internal organs, together with the paralysis of the vasomotor center resulting from the shock. This may play a large part in bringing about the internal congestion. Edema of the glottis, acute bronchitis, and pneumonia are to be looked for particularly when hot vapors or steam, etc.. cause irritation of the mucous lining of the throat. Acute nephritis nearly always follows severe burns due to the congestion, the increased work due to failure of the skin and the increased and highly toxic waste products. The urine may be scanty and general symptoms of suppression will appear. Inflammation of the intestines is more apt to occur following burns of the abdomen. Occasionally a duodenal ulcer develops which may result in hemorrhage or perforation with peritonitis. A dark tarry stool suggests intestinal hemorrhage; persistent vomiting, abdominal pain and distention suggest peritonitis. Treatment for Burns.—As death is most frequently due to shock, the relief of shock should be the first consideration. (See treatment of shock). Local Treatment.—This depends upon the extent and depth. When limited in extent and severity the treatment is rest and the application of cold wet dressings of normal salt solution or a saturated solution of bicarbonate of soda. Picric acid is fre- quently used. It is both antiseptic and astringent and promotes healing. It is not used on extensive burns because of the danger of absorption and poisoning, the symptoms of which are, a yellow skin, fever, diarrhea and dark urine. When using picric acid care must be taken to protect the bed linen, etc., as it stains it yellow. Carron oil, which consists of linseed oil and lime-water, gives relief but as it is difficult to keep the wound surgically "clean," it is considered a "dirty" dressing. Soothing ointments, such as zinc oxid, boric, cold cream or vaseline are sometimes used. The ointments used should be sterile. In burns of the second degree, the blisters are opened with sterile scissors at the lowest border and the fluid is allowed to escape in order to prevent infection. A wet dressing is then applied. NURSING CARE IN ACCIDENTS AND EMERGENCIES 617 Burns of the third degree in which the deep skin and with it nerve endings are exposed must be protected from the air (which increases the pain) and dressed as infrequently as possible to prevent infection and allow healing to take place undisturbed. Antiseptic dressings are applied. Bandages must be put on lightly to allow for swelling. Codein and morphin are given to relieve pain. Clothing must be removed with the greatest care—always cut the clothing to remove. Soak the part thoroughly with peroxid of hydrogen before attempting to remove the clothing. See that the wound is quite clean and free from charred pieces of clothing. Remove the clothing very gradually dressing each part as exposed—never at any time in applying the dressings expose a large area. Burns of the third degree are frequently treated with ambrine or a substitute consisting of a preparation of paraffin wax, white wax and resin cerate which melt at a low temperature. The ambrine or its substitute is melted over a water bath, is then poured into an atomizer from which it is applied to the burned area. The wound is first thoroughly cleansed with boric acid or salt solution. A thin layer of cotton is then applied and sealed with more wax. This excludes air, prevents infection and sup- plies an aseptic dressing beneath which healing can take place. When heating the wax never bring to the boiling point as it will cause it to crumble when applied. Ointments containing phenol are frequently used. Phenol acts as a local anesthetic, is anti- septic and prevents any disagreeable odor from the sloughing tissue. These ointments, therefore, give comfort to the patient mentally and physically and prevent him from being a source of discomfort to others in the ward. Extensive burns may be treated with continuous wet dress- ings, by immersion or by the "open treatment." In treating burns of the hands and fingers place gauze between the fingers to keep them apart otherwise they will become webbed in heal- ing. Treatment by immersion may be used for an extremity or for the entire body. Mild antiseptic solutions are usually used such as boric acid or water containing bicarbonate of soda. The temperature should be neutral that is, 92° to 97° F. This ex- cludes the air and surrounds the part or the body with a neutral medium which is soothing to the nerve endings and thus relieves shock, pain and restlessness. It keeps the surface clean and pre- vents the absorption of toxic products. The temperature must be kept even throughout and the solution must be changed at least once during the day during which process sterile dressings are applied or the body may be wrapped in a sterile sheet. The bath must be arranged so as to cause no discomfort, strain or exertion on the part of the patient. Suppurating areas may be treated by immersion in an antiseptic solution. Warm antisep- tic dressings may be used. They must be changed frequently and the area irrigated and treated like any discharging wound. The "open treatment" consists in surrounding the part with 618 THE PRINCIPLES AND PRACTICE OF NURSING air kept at an even temperature of 100° F. This causes a thick, dry crust to form quickly over the area under which healing, by the formation of granulations, takes place. This is called heal- ing under a crust. This crust forms a protective covering pre- venting infection, excluding air and relieving discomfort. If the resistance of the tissues is lowered infection with suppura- tion may occur under the crust with absorption of septic prod- ucts and general toxemia. Watch for an elevated temperature, a rapid pulse and the symptoms of toxemia. The treatment is to remove the crust with a warm bath 96° F. containing bicar- bonate of soda which softens the crust. The crust is allowed to form again or moist antiseptic dressings may be used. When this method of treating wounds is used, care must be taken to ex- clude flies. They may lay their eggs in the wound, which rap- idly hatch into larvae or maggots. Burns caused by Corrosive Poisons.—The chemical substances may be acids or alkalies. Burns caused by acids should be irri- gated freely with alkaline solutions to neutralize the acid. Lime- water, weak ammonia or a solution of bicarbonate of soda may be used. Carbolic acid or creosote should be neutralized by alco- hol or whisky after which a dressing of alcohol or a soothing ointment may be applied—oil should not be used as it hastens the absorption of carbolic acid. Burns caused by alkalies (caus- tic soda, caustic potash or ammonia, etc.) should be treated with boric acid, vinegar and water or lemon-juice and water. The systemic treatment of burns consists in the relief of shock, toxemia, congestion of internal organs, and nephritis. Shock is relieved by rest, quiet, external warmth, stimulants, the relief of pain and immediate attention to the burned area. Pain is a powerful factor in producing shock and must receive immediate relief—morphin is usually necessary. Pain must be avoided in removing clothing and in all subsequent dressings. Toxemia is relieved by the proper care of the wound—keeping it clean, free from infection, removing sloughing tissue or septic discharges and preventing their absorption; and by diluting the toxic products and flushing them out of the system—by forced fluids by mouth, rectum or hypodermoclysis, by keeping the bowels open with cathartics and increasing the elimination by the kidneys. Meningeal irritation with headache, delirium and restlessness, etc., is relieved by an ice-cap applied to the head and the admin- istration of sedatives, usually bromids. Congestion of internal organs may be prevented by the appli- cation of cold compresses or the ice-coil. Turning the patient frequently, and steam inhalations to soothe the irritated mucous membrane of the respiratory tract will help to prevent pneu- monia. Liquid diet and keeping the intestines free from irritat- ing matter will help to prevent intestinal inflammation. Acute nephritis may be prevented or relieved by lessening the work of the kidneys and aiding them in eliminating the waste and NURSING CARE IN ACCIDENTS AND EMERGENCIES 619 poisonous products. Their work is lessened by limiting the diet to milk and other fluids and by increasing the elimination by the intestines, also by preventing the absorption of toxic and septic products. Eliminations are aided by forced fluids, lemonade, im- perial drink and other diuretics. Local Complications of Burns.—The burned area may be- come infected with pyogenic organisms commonly found in the skin. This may result in suppuration and general toxemia from the absorption of septic products or septicemia from the inva- sion of the blood stream by bacteria. Infection by the strepto- coccus pyogenes or erysipelatis causing erysipelas may occur, particularly in burns about the face. Extensive sloughing of the tissues may lead to a secondary hemorrhage. Embolism may occur from the entrance of tissue cells into the blood stream. Contraction of the tissues in healing may occur with an un- sightly scar and if near a joint, stiffness and limited motion. FROST-BITES Frost-bites occur as the result of prolonged exposure to ex- treme cold. The parts of the body most commonly affected are the fingers, toes, ears, nose, and the skin over the cheek bones. These are the most exposed parts, the blood vessels are near the surface so quickly affected by the cold, and the blood is soon chilled. The circulation in the extremities is also apt to be poor while the ears, nose and cheek are not protected by clothing or hair. The injury is said to be due to the direct effect of the cold on the fluids in the tissue cells. It is a well-known fact that water expands in freezing. The injury is described by Dr. W. G. Mac- Callum as follows:—"The noxious effect of the freezing is ex- plained either as due to mechanical tearing of the cell as the ice crystals are formed, or to the concentration of salt around the crystals, or to the withdrawal of water from the cell to form the ice." The result is a serious inflammatory reaction or gan- grene. It is further explained "that the gangrene of the ex- tremities which "follows such chilling is by no means always directly due to the cold. On the contrary, it is the result of protracted ischemia from extreme contraction of the blood vessels or their obstruction by thrombi." The parts are at first livid; later, as venous congestion occurs, cyanotic, swollen and pulseless, then turn purple and finally a greenish-black. Chilblains may occur in the fingers and toes as the result of exposure to less extreme cold, with moisture. The parts are at first pale due to contraction of the blood vessels and the result- ing anemia. Later they become cyanotic and, when in the warmth, remain purplish but swell and become extremely pain- ful and disabled. The treatment in the early stage of frost-bite consists of rubbing the part with snow or a cloth wrung out of,ice-cold 620 THE PRINCIPLES AND PRACTICE OF NURSING water, gradually making the applications warmer. The patient should not be brought into a warm room until the color of the part is normal, showing that the circulation has been reestab- lished. The aim is to restore the tone of the blood vessels and allow the blood to return gradually. The application of heat to a frozen part in which the vessels are paralyzed and engorged with venous blood would further reduce their tone and increase the supply of blood so rapidly as to cause rupture and bleeding into the tissues and almost certain death of the part. When the circulation is reestablished, a loose dressing is applied, with warmth and elevation of the part to improve the circulation. If sloughing occurs, hot antiseptic dressings are usually applied to hasten the separation of sloughs and to lessen the danger from the absorption of septic material. If gangrene develops it is usually of the dry type. The part is kept dry, may be dusted with a dry antiseptic powder, and covered with an absorbent cotton dressing until separation takes place at the line of demarcation or, in some cases, it is removed by amputation. CHAPTER XXXVI NURSING CARE IN ACCIDENTS AND EMERGENCIES (Continued) INJURIES TO BONES AND JOINTS Injuries to bones and joints such as sprains, dislocations, and fractures are among the common accidents which occur in which a nurse should be able to give immediate relief before the arrival of the surgeon, and which often demand skilled nursing care in the after-treatment. The treatment and nursing care of such accidents will be discussed in the present chapter. SPRAINS A sprain is an injury to a joint caused by a sudden, violent movement—a wrench, a twist or a strain which, if continued, would result in a fracture or dislocation. The result is bruising of the synovial membrane, which causes very severe and sometimes sickening pain because of its abun- dant nerve supply; a rupture or severe stretching of the liga- ments, tendons and muscles which support the joint; and a rup- ture of blood vessels with bleeding into the tissues and often into the synovial sac. This injury to the tissues is followed by an inflammatory reaction which gives rise to an inflammatory exudate in the ligaments, tendons, muscles, subcutaneous tissue, and sometimes into the synovial sac. Sprains of the wrist and ankle are the most common because these joints are more exposed to injury, but sprains of the elbow and knee and other superficial joints also occur. Symptoms.—There is first very severe pain, sometimes so severe as to cause fainting or nausea and vomiting. The joint swells quickly, is extremely tender to the touch, and soon be- comes discolored if the surface blood vessels have been injured. Discoloration from rupture of the deeper vessels may not appear for a day or two. When the inflammatory reaction begins there is heat and increased swelling, tenderness and pain on motion. Treatment.—A sprain is often very wrongly considered a slight injury—"just a sprain"—when in reality it may be a very serious injury. A fracture may be very easily and is frequently mistaken for a sprain. Even a surgeon is sometimes unable to determine the diagnosis without the aid of the X-Ray and some- 621 622 THE PRINCIPLES AND PRACTICE OF NURSING times a general anesthetic. Even a sprain, if neglected or care- lessly treated, may result in a permanently weak joint or in a partial or complete stiffness with continued pain. It is danger- ous to attempt to "walk off" a sprain of the ankle unless it is very slight or has been properly treated and supported by a surgeon. The treatment depends upon the severity of the case and also varies with different surgeons. Efforts are first made to relieve the pain, to arrest the hemorrhage and serous effusion and to aid its absorption. Sometimes cold applications in the form of ice- compresses, aluminium acetate, or aluminium and opium solu- tion are used with the part elevated and kept at rest. Some- times the part is immersed in hot water, the temperature being gradually increased until it is as hot as the patient can stand. This relieves the pain, contracts the blood vessels and lessens the hemorrhage and effusion. The part is then tightly bandaged to prevent further congestion. Sometimes the part is strapped firmly enough to give support and relieve the strain without preventing movement and the patient is encouraged to use the part freely. This helps to maintain a free circulation and to prevent stiffness. For severe sprains well-padded splints or molded plaster-of-Paris casts may be used. For a sprained wrist the arm may be supported and elevated by a sling. To increase the circulation about and in the joint local applications of heat (baking, electric light, high frequency current, hot water), massage, and passive movements are used. DISLOCATIONS A dislocation is the separation of the articular surfaces of two or more bones entering into the formation of a joint. Symptoms.—There is first sickening or nauseating pain, greatly increased by motion of the part which causes pressure of the dislocated bone on nerves, etc. Deformity with a length- ening or shortening of the limb occurs depending upon the line of displacement. There is limited motion or loss of function in the part. After the reduction there is no tendency to a redis- placement as in a fracture. There may be swelling of the sur- rounding tissues. Some degree of shock is nearly always present. Complications which may Occur.—Injury to blood vessels, nerves and soft tissues, or contusions may occur. One or more bones may be fractured. The dislocation may be compound, that is, an external wound leads to the injured joint. A severe hem- orrhage resulting in a hematoma sometimes occurs. Treatment.—First Aid.—The limb should be put at rest in the position most comfortable for the patient. For a dislocation of the joints of the upper extremity—shoulder, elbow, or wrist —apply a splint or a bandage and support the arm in a sling. For a dislocation of the hip, knee, or ankle, the patient should be put to bed and a splint applied as in a fracture of the femur. NURSING CARE IN ACCIDENTS AND EMERGENCIES 623 To lessen the pain and swelling, ice compresses or lead and opium solution may be applied. Treat for shock if present. The reduction of a dislocation requires both considerable knowledge and skill, and should never be attempted by an inex- perienced person if it is at all possible to obtain the services of a surgeon, even after the lapse of many hours. Permanent injury may be done by improper manipulation. Frequently a general anesthetic is necessary to relax the muscles and relieve pain before re- duction is possible. Surgical Treatment—(Brewer). —The dislocation is reduced by manipulation and extension or by open operation. Reduction should be accomplished as soon as pos- sible because the injury is followed by a marked inflammatory reac- tion with considerable exudation which (if reduction is not secured) later forms dense fibrous material which fills up the socket or forms adhesions binding the bone in its abnormal position. The attached muscles also become contracted limiting the function of the part. Restoration of function in the joint and muscles is secured by gentle passive motion. Later massage, baths, and electricity are used. Compound dislocations exposing the larger joints are extremely se- rious, and demand an extensive operation. The shock and injury to the surrounding tissues, blood vessels and nerves are usually very severe. The danger from infection and general sepsis is great and am- putation is often necessary. Fig. 135.—Compound Fracture (DaCosta). (From Owen's "The Treatment of Emergen- cies," W. B. Saunders Co., Publishers.) FRACTURES A fracture is an injury which produces a solution of the continu- ity of a bone, that is, a break or violent separation of a bone into two or more fragments. Varieties of Fractures.— 1. A simple fracture is one in which the bone is broken but the skin and surrounding tissues are unbroken. 2. A compound fracture is one in which a wound in the skin and surrounding tissues exposes or leads to the ends or frag- ments of the broken bone. 3. A comminuted fracture is one in which the bone is crushed, 624 THE PRINCIPLES AND PRACTICE OF NURSING splintered, or broken into a number of small fragments, the lines of the break communicating with each other. The general direc- tion of the break is indicated by the terms transverse, longitu- dinal, oblique, spiral, T or V-shaped. 4. An impacted fracture is one in which one fragment of bone is forcibly driven into another and remains more or less fixed in that position. 5. A greenstick fracture is one in which the shaft is bent and cracked but not completely broken through. This frequently happens in children because their bones are not yet fully hardened or cal- cified, but are still young and elastic like a green twig. Other incomplete fractures are depressions where a portion of a flat bone is driven inward, but not severed—depressions Fig. 136. A Com- minuted Fracture (DaCosta). (From Owen's "Treat- ment of Emergen- cies," W. B. Saunders Co., Publishers.) . 137.—Impacted Fracture of the Tuberosities of the Hu- merus. (From Morrow's "Im- mediate Care of the Injured," W. B. Saunders Co., Publish- ers.) of the skull are frequent; and separations at the epiphyseal line in early life before complete union has taken place. 6. The terms single, double, and multiple refer to the number of breaks occurring in a bone; the terms recent, old, united or ununited refer to the time of the injury and the degree of repair which has taken place. Fractures are also Classified into: 1. Fractures of the diaphyses (shafts) in which motion is felt at a point where there should be none, the broken ends of the bone tend to overlap (due to the weight of the limb and the pull of muscles), causing more or less shortening of the limb. 2. Fractures of the epiphyses (extremities) in which the articu- lations are frequently involved. A Colles' fracture is a fracture of the lower end of the radius and of the styloid process of the ulna. It is frequently called NURSING CARE IN ACCIDENTS AND EMERGENCIES 625 138(a) l' the "silver fork" fracture because the char- acteristic deformity gives the limb the ap- pearance of a fork. A Pott's fracture is a frac- ture of the lower end of the fibula and of the internal mal- leolus (tibia). How to Recognize a Frac- ture.—1. By the subjective symptoms—pain and loss of function. Following an acci- dent, if the injured person complains of pain and inabil- ity to use the injured part, or severe pain on attempting to use it one should suspect a fracture and treat according- ly. For instance, if in an ac- cident, a man has fallen and is unable to get up or is un- able to walk or if he is unable to use an injured arm or hand, the bones of the leg or arm are probably fractured. He may even be able to walk and still have a fracture of the fibula because this bone gives little support and the tibia will act as a splint for it. Again the ability or inability to use the fingers is not a safe test, as is popularly supposed, of a suspected fracture of the bones of the forearm. They may still Fig. 138. Green-stick Fracture (Da- Costa). (From Owen's "Treatment of Emergencies," W. B. Saunders Co., Publishers.) Fig. 138a.—A Multiple Fracture. Fig. 139.—Colles' Fracture Showing the Characteristic Deformity, (From Owen's "Treatment of Emergencies," W. B. Saunders Co., Pub- lishers.) 626 THE PRINCIPLES AND PRACTICE OF NURSING be used, though with great pain, even though these bones are broken. Following an injury to the pelvic region the inability to stand or sit, a feeling of "coming apart," or bleeding from the rectum or bladder point to a fractured pelvis. Severe pain on breathing or coughing, or bloody expectoration following a chest injury suggests, a fracture of one or more ribs. In fractures of the skull the symptoms may be absent or very slight. There may be merely headache and mental confu- sion or there may be unconsciousness and paralysis with a slow pulse and breathing. 2. By the objective symptoms.— There will be localized tenderness and abnormal mobility that is, movement where there should be none, as for in- stance between the shoulder and el- bow. Deformity usually occurs due to the displacement of the broken ends, to hemorrhage from the deep muscles or periosteum, and swelling of the soft parts. The displacement is due to the pull of muscles attached to the fragments. The limb may be wm WuV^Sj m an unnatural position (due to the Wf »^ ^H pull of muscles and weight of the limb) with a characteristic deformity. Overlapping of the broken ends may cause one limb to be shorter than an- other. Crepitus may be present due to the displacement of fragments and the grating caused by the rubbing to- gether of the ragged edges. This may be felt by the examiner and sometimes heard but should not be searched for because the slightest movement of the ragged bone fragments adds further injury to the surrounding tissues. Swelling and discoloration, due to injury of the surrounding tissues, may be present. In a fracture of the base of the skull there may be bleeding from the ear from rupture of the tympanic membrane. The blood may also pass along the Eustachian tube and escape through the nose or mouth or it may be swallowed and vomited later. The blood may also escape into the orbit turning the white of the eye red (ecchymosis). Cerebrospinal fluid may also escape due to rupture of the dura and arachnoid membranes. Cranial nerves (which pass out from the base of the brain) may be in- jured, especially the facial and auditory nerves, resulting in facial paralysis and deafness. Sometimes the use of the X-Ray is the only means of making Fig. 140.—Pott's Fracture (Fowler). (From Mor- row's "Immediate Care of the Injured," W. B. Saun- ders Co., Publishers.) NURSING CARE IN ACCIDENTS AND EMERGENCIES 627 an accurate diagnosis. In fractures of the spine or skull the diag- nosis is made chiefly by the observation of symptoms of injury to the brain or spinal cord, by the use of the X-Ray, or by an exploratory operation. Systemic Symptoms.—In all injuries due to violence the pa- tient will suffer from shock which will be more or less severe and prolonged. Fractures of the skull, .spine, pelvis and femur are especially apt to be accompanied by shock. Frequently there will be gastric disturbances, general malaise, and a slight rise in temperature. Complications which may Occur or Develop.—Injury and bruising of the surrounding tissues—the skin, muscles, fascia and joints, etc.—may occur. Nerves may be torn, bruised or stretched. Internal organs such as the lungs, pleura, or bladder may be perforated or the brain or spinal cord may be injured. Blood vessels may be injured. Nerves and blood vessels are especially apt to be injured when they lie in close contact with the bone as in fractures of the humerus and femur. For this reason the pulse at the wrist in a fractured arm and at the dor- sum of the foot in a fractured leg should always be carefully examined. Injury to the arteries may give rise to traumatic aneurysms and injury to the main arterial trunk of a limb, upon which its nourishment and life depend, may cause an advancing gangrene requiring amputation. Injury to blood vessels may result in hematoma which by pressure may cause edema and gangrene. Infection may occur and should be guarded against in all com- pound fractures, and in fractures of the skull, nose, or jaw, which are frequently compound. The nose and mouth are never free from germs. In fractures of the base of the skull, the nose and ears must be kept clean and infection prevented from entering by placing sterile cotton in the nostrils and ears. Infection may cause meningitis or septicemia either of which may prove fatal. Ischemic (anemic) paralysis sometimes occurs. This is a form of paralysis and deformity due to pressure which temporarily shuts off the supply of arterial blood from the part and often results in the permanent loss of function of an extremity. The most frequent causes are the application of circular casts of plas- ter-of-Paris, tight bandaging, or too tightly applied splints to a fresh fracture, which does not allow for the increased blood supply which always occurs in an injured part with exudation and swell- ing of the tissues. The increasing pressure on the soft parts causes an acute ischemia of the parts, which if unrelieved for six or more hours, produces such marked degenerative changes in the muscles and nerves that paralysis and a permanent con- traction of muscles follows with sensory and nutritional dis- turbances and in some cases gangrene. This usually occurs in an extremity, most frequently in the forearm. Most of the venous blood from the hand and arm returns by superficial veins which are readily affected by pressure. 628 THE PRINCIPLES AND PRACTICE OF NURSING The symptoms of this very serious condition which must be closely watched for are pain, coldness, numbness, edema and cyanosis of the extremity. In order that these symptoms may be recognized :mmediately, the fingers and toes are always left exposed, and if any of the above symptoms appear, they should be reported immediately so that the bandage, splint or cast may be removed or loosened. Fat-embolism.—Sometimes fat globules from the bone marrow of the broken bone enter the blood stream and are carried along until first arrested in the pulmonary capillaries where they form a plug shutting off the circulation. Sometimes they are carried along until they become lodged in the capillaries of the brain or other viscera. This condition may prove rapidly fatal. The symptoms which warn us of this very grave condition are cyan- osis, rapid, labored breathing with extreme shock and sometimes restlessness, delirium, and coma. Restlessness, insomnia, and delirium tremens may be present in alcoholics. This is said to be because the accident frequently occurs during or after a state of intoxication. Alcohol is a pow- erful depressant so that the shock from the injury is apt to be more severe in an alcoholic patient. Late Complications which may Develop.—Motion in the joint may be limited. Paralysis may result from injury to a nerve trunk or from the pressure of callus. Poor circulation may cause atrophy of muscles with resulting weakness and lack of use. Delayed union, non-union or vicious union (union with deformity and loss of function) may take place. In the fore- arm, faulty reduction or excess callus may limit the space be- tween the radius and ulna and so limit its normal rotation in pronation and supination resulting in a stiffened elbow and loss of function of the arm and hand. Repair of a Fractured Bone.—The repair of a fractured bone depends upon the extent of the injury to the bone, the periosteum, the nutrient blood vessels, the nerves, the surrounding tissues, the presence or absence of infection, the condition of the patient, and the treatment given. When, by proper treatment, the fragments of a broken bone are accurately replaced and kept at rest in their normal rela- tions, repair takes place very rapidly (in from three to six weeks), in the absence of infection, if the part is well supplied with healing blood and the injury to the periosteum is not too great. In fractures the broken ends of the bone are quickly sur- rounded by a hemorrhage, from the bone marrow and surround- ing tissues, which is soon checked by clotting. The injury to the soft tissues—muscles and fascia—calls forth a slight inflam- matory reaction with a resulting hyperemia and exudation of fluid and leucocytes into the tissues with swelling around the broken fragments. Fresh supplies and more workmen are thus rushed to the spot to repair the damage and carry away the debris. NURSING CARE IN ACCIDENTS AND EMERGENCIES 629 The osteoblasts (active bone-forming cells) from the endos- teum and inner vascular layer of the periosteum are the master- builders who immediately begin to repair or rebuild the new bone following Nature's (the architect) plan that is "by methods identical with those concerned in its first formation" (Mac- Callum). The periosteum is essential because bone is probably not formed by the bone corpuscles which are buried in the rigid bone (MacCallum). A cement-like substance called callus is produced and poured around and between the broken fragments cementing them together and forming, so to speak, the frame- work of the new building. This callus is at first a homogeneous ground substance (like cartilage) inclosing the newly-formed bone cells. New blood vessels from the periosteum gradually extend into it, giving it new life; tough fibers are erected or extended until they permeate the whole mass, converting it quickly into a firm hard tissue which may be felt around the broken bone by the end of the first week. The blood deposits lime salts in the callus so that in from three to six weeks it is converted into new bone. Although for a time the building may be clumsy and imperfect in design, it serves a useful purpose and, by degrees, alterations are made until it becomes wonder- fully like the original plan designed by Nature. In the meantime the blood and lymph and the assistant work- men (leucocytes) are busy picking up and carrying away the external and internal scaffolding or buttresses (the excess callus around the bone and in the medullary canal) which are no longer needed for support, until finally the ground is quite clear, the building is ready for use, and the function is normal. Now if the bones have not been properly replaced (the respon- sibility of the surgeon) or if replaced and then disturbed by more or less movement (the responsibility of the nurse), Nature will do her best to bridge the gap, but the repair will be slower, the building will be sprawling, so to speak, and take up ground belonging to the muscles and so greatly interfere with their func- tion. The result may be a permanent deformity and loss of function. This would be a very serious handicap for which no nurse would want to be responsible. In an extensive comminuted fracture, new bone forms around and between all the fragments and, if not properly treated, may extend into the muscles and may also surround and include nerves with consequent impairment or loss of function in the part. The repair of bone and of the surrounding tissues depends to a large extent on the free circulation of healing blood in the part. Injury or treatment which interferes with the blood supply may cause death of bone tissue and result in non-union or a greatly prolonged process. The repair of a compound fracture is the same as that of a simple fracture, and the repair of the soft parts the same as that outlined on page 564, either by primary union or by the formation of granulations. 630 THE PRINCIPLES AND PRACTICE OF NURSING Infection greatly delays the union of a broken bone. It also causes death of portions of the bone and the formation of sinuses leading to the dead fragments or sequestra, which do not close but continue to discharge until all the dead bone has been re- moved. The resulting abscesses may spread to the muscles and fascia, the tissue destroyed be replaced by scar tissue which will greatly interfere with the function of the part. It is said that a mild infection stimulates bone formation so that an excessive irregular growth of callus results, encroaching on the muscles and joints and interfering with their function. Delayed Union or Non-Union.—Sometimes for various reasons the bones fail to unite. This may be due to infection, to the presence of dead bone, to faulty position, to constant slight movement, to removal of too much bone, the healing over of the broken ends and plugging of the medullary cavity with callus; to poor circulation in the part, lack of an inflammatory reaction or to the general condition of the patient with feeble powers of repair. General Factors to be Considered in the Treatment of Frac- tures.—The treatment in general may be considered under three main headings: 1. First-aid treatment. 2. Reduction and immobilization 3. After-treatment. The responsibility of the nurse. First-aid Treatment.—This is extremely important for it determines the whole aftercourse—the duration, the restoration of function, the loss of a limb, and even the life of the patient depend upon it. The important things to remember in the first-aid treatment are as follows: The main object is to prevent further injury. If a doctor can be quickly summoned, and the injured person has fallen but is in a place of safety, it is wisest for an inexperi- enced person to merely make the patient comfortable with pil- lows, etc., where he lies, disturbing the part as little as possible. One should always remember the danger of shock and keep the patient in the recumbent position with the head low (except in suspected fracture of the skull), and as quiet as possible. If there is a wound, bleeding, if present, must be checked and every precaution must be taken to prevent infection. The clothing should be removed, cut away if necessary and removed from the uninjured side first. The wound and surrounding skin should be painted with 2 per cent, iodin, covered with a sterile pad and bandaged. Later more thorough treatment is given under strictly aseptic conditions. The part should, if possible, be put completely at rest or im- mobilized. It should be placed in a position which tends to cause relaxation of the muscles, the contractions of which are causing pain and displacement. A patient will often instinctively do this for himself. For instance, in a fractured clavicle he in- clines his head to the injured side, raises his shoulder and sup- NURSING CARE IN ACCIDENTS AND EMERGENCIES 631 ports his elbow; in a fracture of the upper extremity, he will support his elbow, forearm, wrist or hand; in a fracture of the ribs, he will take shallow breaths, lean toward the injured side and press his hand against it. Rest and immobilization are nec- essary in order to relieve pain, prevent further displacement of fragments and further tearing (by ragged edges of bone) of the soft tissues, blood vessels or nerves. An extremity must never be allowed to dangle and even after splints, etc., are applied the patient must not be allowed to attempt to use the foot. For in- stance, he must not stand or attempt to walk when a fracture of the lower extremity is suspected. In handling the fractured part the utmost care and gentleness must be used. All cases should be handled as little as possible. In lifting a limb it should always be carefully supported under the broken ends and under the joints above and below the break. Movement at either joint must further displace the fragments. It is best to apply an even support to the whole limb before lift- ing. Careless handling may make a simple into a compound fracture, a very grave accident with danger of infection, loss of a limb or even of life. It may cause nerves to be torn or bruised and blood vessels to be injured which may result in a severe hemorrhage, or gangrene, and necessitate amputation. One should watch for discoloration and note whether the pulse in an extremity is present and normal or not. One should also watch for symptoms of internal injury to the brain, spinal cord, lungs, bladder or rectum. Swelling of the part adds to the pain and greatly hampers the proper reduction of the fracture. Pain is always to be avoided as far as possible. It is one of the common factors in the de- velopment of shock. Swelling and pain may be prevented by applying ice to the part, proper support and elevating where possible. All patients suffering from shock or painful contusions, from fractures of the skull, pelvis or lower extremity should be car- ried on a stretcher, with as little jolting as possible, to their home or to a hospital. First-aid Methods of Securing Immobilization.—The part may be immobilized by the application of (1) bandages; (2) adhe- sive strapping; (3) splints. Bandaging is used chiefly in the following cases: A four-tailed bandage or a Barton bandage may be used for a fractured jaw; a Velpeau bandage for a fractured clavicle. In the absence of splints a fractured arm may be bandaged to the side (the axilla and side being first well-padded) and a fractured leg to the other leg, in this way using the patient's own body as a splint. A bandage or tight binder is sometimes used for fractured ribs but must not be left on too long as they restrict the action of both lungs. A triangular bandage in the form of a sling is used to support the forearm in fractures of the clavicle, arm or hand. A tight binder may be applied around the hips and the knees 632 THE PRINCIPLES AND PRACTICE OF NURSING bandaged together to give support and immobilize the hips in a fractured pelvis. Adhesive strapping is used chiefly for a fracture of one or more ribs. Splints should be light in weight but firm enough to give sup- port. Anything—an umbrella, cane, or folded pillow, etc.— which will serve this purpose may be used in an emergency, but splints of soft pine or basswood are best. They should be wider than the part, if possible. Splints should be long enough to fix the joints above and below the fracture. For instance, in a frac- tured humerus, a splint applied to the outer surface of the arm should extend from the shoulder to the tip of the flexed elbow. For a fractured forearm, the splint should extend from the elbow to the base of the fingers or to the finger tips depending upon the seat of the fracture. The hand and fingers must never be left in a cramped position. Sometimes the fingers are left free to allow free movement of the joints. Some surgeons, however, always include and support the hand by the splint in order to prevent swelling, discomfort and pain. The fingers are left ex- posed so that disturbances in the circulation may be observed. The arm is placed across the chest with the palm inward and thumb up and is supported in a sling. This keeps the bones apart, prevents union and in case of partial loss of function the arm and hand are in a useful position. For a fractured femur, the outer splint should extend from the axilla to below the foot. For a fracture of the lower leg, the splints should extend from above the knee to below the foot. Two or more splints should be used to support a limb where possible. Splints must always be well padded especially over tender areas, over bony prominences such as the shoulder, elbow, wrist, hip, knee or ankle and also in hollows such as the axilla, flexed elbow or groin. They may be held in place by straps of adhe- sive or by a bandage but must never be applied too tightly. If not well padded or if applied too tightly the pressure will cause swelling, pain, blisters, ulcers, sloughing of tissues and may re- sult in paralysis or a permanent impairment of function. In applying splints to the arm or leg, hollows, such as the palm of the hand and under the knee, should always be well padded. In the hand this support prevents discomfort and maintains its normal arch. In the treatment of a fractured femur the knee is always slightly flexed. This prevents the knee from sagging backward and maintains the normal anterior bowing of the femur. Proper support relieves the pain due to strain and stretching of the tendons. Before splints are applied the part should be very carefully and gently cleansed, dried and powdered. Sandbags, when placed at either side of the injured part, are of service in preventing the twitching of muscles or movement of the part. Reduction and Immobilization of the Fracture.—In all cases NURSING CARE IN ACCIDENTS AND EMERGENCIES 633 the fracture should be reduced as soon as possible in order to prevent overriding or overlapping of the broken ends with further injury to the periosteum and other tissues, etc. Some bones also, such as those of the nose, tend to unite quickly so if not promptly and properly reduced will result in deformity. Sometimes the fracture may be reduced, that is, the bones may be brought approximately into apposition, by very gentle ma- nipulation and immobilization secured by means of bandages, adhesive strapping or splints of wood, metal, or plaster-of-Paris. Splints or casts of plaster-of-Paris are usually used when it is difficult to keep the part at rest and absolute fixation is neces- sary, as in a fracture of both bones of the forearm or leg. Molded casts of plaster-of-Paris are frequently used for the extremities. A shoulder spica is frequently used for a fractured Fig. 141.—The Thomas Traction Arm Splint. (From Blake's "Gun-shot Fractures of Extremities," D. Appleton & Co., Publishers.) arm, a hip spica for a fractured femur and a body cast or jacket for a fractured spine or pelvis. Usually an anesthetic is given to avoid pain, relax the muscles and allow the surgeon to work to the best advantage. Fre- quently pain, swelling, or muscular rigidity make it difficult to determine the exact position and nature of the fracture so that replacement must be done under a general anesthetic and under the guidance of the X-Ray. The patient is kept under observa- tion and the part examined again under the X-Ray to verify the position and observe the process of repair. Many fractures for various reasons cannot be reduced by simple manipulation or the bones maintained in their proper position. In such cases reduction and fixation must be secured by open operation, or gradually by means of traction or trac- tion combined with suspension obtained by the use of various external appliances. The latter method was used extensively and many improvements were developed in the treatment of fractures during the past war. 634 THE PRINCIPLES AND PRACTICE OF NURSING Traction is the "extension of the member in what may be called the physiological direction and position." It is used when the broken ends of bone are overlapping thus causing lateral de- formities and shortening of the limb. Its object is to prevent overlapping of the bones and thus prevent deformities. Trac- tion is accomplished by the use of weights, by using the we.ight of the patient, and by the use of various splints. The traction pull may be on strips of adhesive attached to the skin as in the Buck's extension used for a fractured femur. It may also be made on a stocking or gaiter glued to the foot or by means of the Sinclair skate. For fractures of the arm traction is sometimes Fig. 142.—The Jones Traction Humerus Splint. (From Blake's "Gun- shot Fractures of Extremities," D. Appleton & Co., Publishers.) made on a cotton glove glued to the hand. The splints com- monly used are the Thomas traction arm splint, the Jones trac- tion humerus splint, the Jones wrist splint, the Thomas traction leg splint and the Hodgen leg splint (a suspension splint). A nurse should be familiar with the various appliances used and the articles necessary for their application and should see that the part is properly prepared. Before traction is made by means of adhesive strapping, etc., attached to the skin the part should be shaved, cleansed and thoroughly dried. Extreme care and gentleness in handling must be used. Buck's extension is not used as frequently as in the past but a nurse may have to collect the articles necessary for its applica- NURSING CARE IN ACCIDENTS AND EMERGENCIES 635 tion. Briefly they are as follows: A fracture board to render the mattress firm; blocks if necessary to elevate the foot of the bed; two pieces of moleskin (about four inches wide and long enough to extend from the side of the foot to above the knee) with suspender-buckles attached; a spreader consisting of a piece of wood five inches long by three inches wide to which is attached a strip of webbing about one inch wide and long enough to extend about six inches on either side, so that they may be Fig. 143.—Thomas Traction Leg Splint. (From Blake's "Gun-shot Frac- tures of Extremities," D. Appleton & Co., Publishers.) Fig. 144.—Half-ring Modification of the Thomas Traction Leg Splint. (From Blake's "Gun-shot Fractures of Extremities,"- D. Appleton & Co., Publishers.) Fig. 145.—Hodgen's Leg Splint. (From Blake's "Gun-shot Fractures of Extremities," D. Appleton & Co., Publishers.) fastened to the suspender-buckles; a piece of rope which is passed through a hole in the spreader and securely knotted, a pulley (with screws to attach it to the bed) over which the rope is passed, and weights suspended on the rope by means of which traction is made. Matches and an alcohol lamp will be neces- sary to heat the moleskin so as to make it adhere. Gauze band- ages may be used to secure the moleskin firmly. A splint may be used to support the limb, to prevent eversion of the foot and the toes from turning out (the characteristic deformity in a frac- 636 THE PRINCIPLES AND PRACTICE OF NURSING Fig. 146.—Principles of Suspension and Traction for Fractures of the Humerus. (From Blake's "Gun-shot Fractures of Extremities," D. Appleton & Co., Publishers.) Fig. 147.—Suspension Cradles for Fractures of the Radius and Ulna, and Methods of Installing Traction and Counter-traction. A, Traction by Means of Glued or Adhesive Strips. B, Sinclair's Method of Using a Cotton Glove Glued to the Hand. (From Blake's "Gun-shot Fractures of Extremities," D. Appleton & Co., Publishers.) NURSING CARE IN ACCIDENTS AND EMERGENCIES 637 tured femur), and to slightly flex the ankle to prevent stretch- ing of the tendons with a resulting "drop foot" and impaired function of the ankle. Muslin bandages will be required to secure the splint and non-absorbent cotton for padding. Suspension combined with traction is secured by placing the limb in a cradle (such as the Hodgen's splint for the lower ex- tremity) and suspending it from an overhead frame to which are attached the suspension pulleys and hand grasps. The frame may be provided with a trolley attachment as shown in figure 149. Traction is applied by weights attached to a cord which runs over a pulley. The weight of the patient may be used by elevating the foot of the bed. The limb is placed in the posi- tion which will best provide rest for the muscles causing the dis- placement and deformity. The advantages of this method of treatment are that (1) It insures a better circulation, therefore promotes healing and lessens the danger of bedsores. (2) It allows motion in the joints without interfering with the proper relation of the broken ends of bone and so prevents stiffness of the joints and loss of func- tion. (3) It allows the frequent application of dressings, mas- sage or other treatments. (4) The patient may be propped up in the vertical or semi-recumbent position and by means of the hand grasps may turn and lift himself so that the linen may be easily changed and the back massaged and properly cared for: The danger of pneumonia is also lessened. (5) The patient has less pain and is much more comfortable. (6) The fact that the patient can himself help by systematic exercise of the joints has a beneficial effect on his mind and therefore on his recovery and general health. The Open Treatment of Fractures.—When a satisfactory re- duction of a fracture cannot be made and maintained by the above methods incisions must be made and some internal means of fixation such as plates, sutures, wire, screws, nails or bolts, or an inlay of bone graft must be used. The After-Care and Responsibility of the Nurse.—The after- care is a very important factor in securing a prompt satisfac- tory recovery from a fracture. A nurse should have an intelli- gent appreciation of what Nature and the surgeon are trying to do and should strive to help them reach this goal. Prompt recovery depends to a large extent on the general mental and physical health of the patient. It must be remem- bered that the mind of the patient is not ill but is active and craving something to do during the long days or weeks. It will become ill if the nurse does not minister to mind as well as body. The patient must not be allowed to become depressed, for a depressed brain means a slowing up of all body functions—the secretions, digestion, circulation, and repair all become sluggish. Old people and patients suffering from a fractured pelvis, spine or femur particularly require cheer and encouragement. The general hygienic care and the diet are equally important. 638 THE PRINCIPLES AND PRACTICE OF NURSING Fig. 148.—Showing Balanced Suspension and Traction Method of Treat- ing a Fracture of Neck of Humerus. Patient exercising the elbow- joint. (Courtesy of Henry H. M. Lyle, M.D., St. Luke's Hospital, N. Y., Annals of Surgery, Publishers.) NURSING CARE IN ACCIDENTS AND EMERGENCIES 639 A well-nourished body is prepared to fight disease or infection and to repair tissue so a nurse should see that meals are appe- tizing and of good building material. Rest, sleep, comfort and freedom from pain should be secured if possible. Cramped posi- tions should be avoided. Pressure-sores from poor circulation, splints, casts, or other appliances, friction of clothing or lying too long in one position must be guarded against. Complications such as bed-sores and pneumonia are to be particularly guarded against in old people. A nurse must see that bandages, casts, etc., are neither too tight nor too loose. Symptoms of interference with the circula- tion or nerve supply must be watched for and reported imme- diately. She should see that the mechanical apparatus and weights, etc., are properly adjusted. The supporting straps of cradles must be kept taut and smooth in order to give even support. If the support is uneven or slackened the patient suf- fers from severe pain. When a Buck's extension is used the hollow under the knee should be supported to relieve strain on the tendons and when the heel and leg are elevated the whole leg should be evenly supported. Cradles should be used over the part where necessary to protect it from the bed clothes. The part must not be allowed to become cold. In carrying out treat- ments or dressings, etc., the part must not be disturbed and in doing dressings the bed should be protected to avoid soiling and unnecessary changing of linen. Care must be taken in the use of the bedpan in fractures of the spine, pelvis and femur. Active motion of the adjacent joints (by the patient) which does not endanger the proper position of the fragments is of the greatest importance in stimulating repair and in preventing atrophy of the muscles and stiffness of joints. It is usually begun after the first twenty-four hours. A few days of fixation will often cause irreparable stiffness. Patients are frequently too indolent or do not understand the importance of this exercise so the nurse must explain and encourage the systematic carrying out of instructions given by the surgeon. The restoration of function, the coordination of muscular movements must come to a large extent through re-education. The patient must learn again to make the various movements with his fingers, hands and arms, etc., which will be useful and necessary in his daily life. To accomplish this his mind must will to do so and must consciously direct the movements of separate muscles and the coordination of groups of muscles in the regular practice of the exercises prescribed by the surgeon. Massage is one of the best means of stimulating repair, of pre- venting atrophy of muscles and stiffness of joints and tendons. It stimulates an inflammatory reaction, producing a constant supply of healing blood and a prompt withdrawal of waste prod- ucts. It is applied regularly every day as soon as union is secured and there is no danger of displacement. Pupil nurses o H »—i Q i—i > a > G H I—I c ft C ft a a: c Fig. 149.—Superimposed Picture to Show the Range of Motion Obtained in Exercising the Knee-joint. (Courtesy of Henry H. M. Lyle, M.D., St. Luke's Hospital, N. Y., Annals of Surgery, Publishers.) NURSING CARE IN ACCIDENTS AND EMERGENCIES 641 are not, as a rule, however, required to give massage in such conditions unless they have had special training and experience. When repair is delayed, dry heat in the form of baking or an electric pad is sometimes used to stimulate the circulation and hasten repair. The part is sometimes soaked for fifteen to twenty minutes in hot water several times a day. * PART II — C THE NURSING CARE AND TREATMENTS USED IN DISEASES OF THE EYE, EAR, NOSE AND THROAT CHAPTER XXXVII NURSING CARE AND TREATMENTS USED IN DISEASES OF THE EYE, EAR, NOSE AND THROAT Frequently in the care of patients in the general surgical or medical wards of a hospital treatments to the eyes, ears, nose or throat are required. Only such treatments can be discussed in a text on general nursing. TREATMENTS TO THE EYES A nurse may be required to assist a doctor with an examination of the eyes and to give treatments such as the application of hot or cold compresses, irrigation of the conjunctival sac, the appli- cation of ointments, etc., and the removal of foreign bodies. The eye is such an extremely sensitive and delicate organ and any interference with its function is such a serious handicap that every precaution should be taken to prevent mistakes or accidents in the nursing care. Before giving treatments or apply- ing remedies nurses should understand the anatomy of the eye, the disease from which the patient is suffering, the complications apt to develop, the purpose of the application or treatment, and the dangers and discomforts involved in the procedure. Knowl- edge, skill, delicacy in handling, gentleness, firmness of touch and the most thorough, expert care are required. Examination of the Eyes.—The objective examination, that is examination by sight or inspection and by feeling or palpa- tion, may be conducted in daylight or in a dark room with arti- ficial light by means of oblique illumination (the light at the side and focused on the part examined with a strong convex lens), or with the ophthalmoscope. The duties of the nurse consist chiefly in placing the patient and the light in the proper position and in providing the necessary instruments. These are the lens, ophthalmoscope and tonometer. The lens is used in examining the anterior structures of the eyeball such as the cornea, anterior chamber, iris and lens. The ophthalmoscope is used to examine the interior of the eye. Changes in the internal structures of the eyes occur in various systemic diseases so that an examina- tion with the ophthalmoscope is often of great assistance in , making a correct diagnosis. The tonometer is an instrument for testing the tension or the pressure within the eyeball. Position of the Patient in Relation to the Light.—For exam- 645 646 THE PRINCIPLES AND PRACTICE OF NURSING ination in daylight the patient is seated (in some cases is allowed to stand) facing a window. For examination in a dark room with artificial light, by means of a lens, the patient should be seated in front of the examiner. The light should be about 18 inches to the side of the patient, on a level with the eye and Fig. 150.—Showing Method of Restraining a Child for an Examina- tion of the Eyes. several inches in advance. The light may be on either side of the patient. In examination with the ophthalmoscope, the patient is seated facing the examiner. The light is placed on either side of the patient, several inches to the side and behind so that the light strikes the patient's temple leaving the face in darkness (Dr. May). The light shines into the mirror of the ophthalmoscope and is reflected into the eye of the patient. In an examination of the eyes of an infant or child who resists TREATMENTS TO THE EYES 647 examination, the child should be placed on its back across the lap of the nurse so that its head rests and is steadied between the knees of the doctor, who sits opposite. The nurse should hold the child's hands, and steady its body with her arms sup- porting the back and neck, but allowing the legs to remain free so that when it struggles, the movements will be confined to the legs while the head remains fixed. These precautions are neces- sary not only to aid in the examination but in order to avoid accidental injury to the eyes. One should always guard against the danger of pent-up secretions squirting into the eyes of the nurse or doctor as the tightly closed lids are separated. Instillation of Drops.—Drops of various solutions are instilled into the eye for purposes of examination and in the treatment of diseases. Instillation for Purposes of Examination.—To examine the in- terior of the eye it is necessary that it should be completely at rest. By instilling drops of certain drugs it is possible to dilate the pupil and prevent it from reacting to light. Such a drug is called a mydriatic. The two drugs commonly used are atropin sulphate and homatropin hydrobromate. These drugs also para- lyze the muscles of accommodation—muscles within the eyeball which control the curvature of the lens and make it possible to focus rays of light from objects at varying distances and thus to see them clearly. Such drugs are called cycloplegics. For purposes of examination, two or three drops are placed in the eyes every ten minutes for two or three closes until the pupil is sufficiently dilated. Atropin is also commonly used in the treatment of inflam- matory diseases of the eyes. The effects of atropin are (1) to dry up secretions and thus relieve congestion, swelling and pain; (2) to deaden sensory nerve endings producing a sedative effect; (3) to put the eye completely at rest so promoting healing; (4) to dilate the pupil and prevent or break down adhesions. When the pupil is contracted or only slightly dilated, the iris rests against the anterior surface of the lens. An inflamed iris if allowed to remain in this position would cause adhesions to form and interfere with the reaction of the eye to light or to accom- modation and, therefore, with the sight. When the pupil is dilated the iris hangs free in the anterior chamber. In some people the continued use of atropin causes a marked local irritation with redness, swelling and itching of the eyelids. Some people also are very susceptible to this drug and in these its use may cause general symptoms of poisoning—dryness of the mouth and throat, difficulty in swallowing, nausea and vomit- ing, skin eruptions, flushing of the face, headache, loss of vision, dizziness, excitability and delirium. All patients should there- fore be watched for symptoms of local irritation or of general poisoning and any such symptoms should be reported at once. Sometimes drops are instilled into the eye to counteract the effect of atropin, that is, to contract the muscles of accommoda- 648 THE PRINCIPLES AND PRACTICE OF NURSING tion and the sphincter muscles of the iris. Such drugs are called miotics. They contract the pupil and reduce intraocular tension. The drug most commonly used is eserine. Method of Procedure in the Instillation of Drops.—An eye- dropper is usually used for the instillation of drops. In drawing up the solution from the bottle care should be taken to avoid wasting the drug by drawing up more than required. Excess solution should not be returned to the bottle for fear of con- taminating it. To instil the drops, the head of the patient should be slightly tilted backward. Gently separate the lids, draw down the lower lid with the left hand, ask the patient to look up, then allow the drop to fall on the center of the everted lower lid. The drop should not be allowed to fall on the sensitive cornea. This is unnecessary, startling and very disagreeable. The dropper should not be allowed to touch the lashes, lids or eyeball, both to avoid irritation, and, also, to avoid contamination of the dropper. The lids and cheek should be gently dried from the overflow of the drug or secretions. When the lids are closed the drops will be distributed. A cotton pledget should be held over the inner angle of the eye to prevent the drug from being lost down the lacrymal duct. . The same dropper should never be used for different solutions without first a thorough cleansing in order to avoid mixing and thus spoiling the solution. All drugs used in the eyes should be watched for changes in the color or for the formation of a sedi- ment, showing decomposition. Some drugs are changed by the action of light or by heat or by contact with organic matter such as the rubber on the medicine dropper. Such drugs should be kept in dark bottles, in a cool place, and contact with the rubber should be avoided. The Application of Compresses.—The circulation in the eye- ball or eyelids may be controlled by applications, either hot or cold, chiefly through their effect on the supra-orbital branch of the ophthalmic artery. Another branch of this artery supplies the retina, the delicate membrane containing the nerves of sight. Again other branches supply the nasal cavity, ethmoid cells, eyelids, muscles and tissues around the eyeball. The aim in all applications is to affect the circulation in the diseased area under treatment without unnecessarily interfering with the cir- culation in the surrounding parts such as the nasal cavity or cheek, etc. Thus hot applications to the lids extending over the forehead (but not over the cheek) will dilate the supra-orbital artery and drain the other branches of the ophthalmic, thus re- lieving inflammation and congestion of the eyeball. This is the area to be covered, therefore, in relieving inflammation and con- gestion of the eyeball. Cold applications over this same area, by contracting the supra-orbital artery, would increase the blood supply in other branches and thus cause congestion in the eye- ball. This might rupture the delicate blood vessels in the eye- ball and cause loss of sight. Cold compresses are usually contra- TREATMENTS TO THE EYES 649 indicated in inflammatory diseases of the eyeball. When used for inflammation of the eyelids, they are allowed to cover the eyelids and extend over the cheek, but not over the brow. In inflammation of the eyelids, hot applications are allowed to cover the eyelids and extend over the cheek but not over the eyebrow or over the nose. Heat applied to the latter area would increase the congestion in the eyelids and cause congestion in the nasal cavity and ethmoidal cells, thus predisposing them to infection and disease. Application of Hot Moist Compresses.—Hot compresses are applied in inflammatory conditions of the eyelid or eyeball— the cornea, iris or ciliary bodies, etc. The effects of the moist heat are the same here as in other inflammatory conditions (see effects of moist heat, Chapter XVI) but the eye requires special care on account of its delicacy and the importance of its function. Method of Procedure.—The patient should be in bed in the dorsal recumbent position and at the side of the bed. A towel is placed across the chest. The necessary articles are brought to the bedside. These consist of the compresses, electric stove, basin of water or boric acid and a thermometer to test the solution. The compresses are made of gauze, cotton or lint and should be light but thick enough to retain the heat and moisture. There must be no rough edges or loose threads. The size of the compress and area to be covered depend upon the purpose of the application. When applied for inflammation of the eyelids, the compress should be large enough to cover the eyelids and extend over the cheek but not to cover the eyebrow or extend over the nose. When applied for inflammation of the eyeball, they should be applied over and above the eye extending to the forehead. They should extend over the brow but not over the cheek. (See anatomical factors.) The compresses are ap- plied over the closed lids. The temperature should be as hot as can be borne (115° to 120°) and should be tested with a thermometer. All excess water must be removed to avoid the danger of scalding. To avoid blistering, when the lids are tender, vaseline should first be applied to the lids or the pads may be applied over oiled silk. The application should be made with a firm, sure touch but gently, avoiding the slightest pressure on the lids or eyeball. When applied the pads should be scrupulously clean, also smooth and pleasant to the touch. The duration of the application varies. The pads are usually changed every thirty to sixty seconds for ten to fifteen minutes each hour. Longer or more frequent applications may cause blistering and paralysis of the blood vessels. On removal, the lids should be gently dried. Any moisture allowed to remain will evaporate, drawing heat from the eyelids and leaving a sensation of chilling and pain. Any discharge from the eyes should be considered contagious. 650 THE PRINCIPLES AND PRACTICE OF NURSING When present, each eye should be treated separately. The com- presses should not be used a second time but should be handled with forceps and burned. Application of Cold Compresses.—Cold compresses are used in inflammatory diseases of the eyelids and conjunctiva. They are not applied in diseases of the eyeball on account of the danger of limiting the blood supply, lowering the resistance of the tis- sues and preventing healing. Cold is also only applied to the lids when they are red, showing an active circulation. When mottled, it shows a stasis or slowing up of the circulation, in which condition the doctor may order hot applications. The effects of the cold are the same here as in other inflam- matory conditions, but, as in applying hot compresses, special care must be taken. Method of Application.—The patient should be lying down in a position of rest. A towel should be draped across the shoulders. The necessary articles should be brought to the bedside. These are compresses, a basin containing a block of ice and a small amount of water or a basin of boric acid to moisten the com- presses. The compresses should be made of lint, gauze or soft muslin, the thickness depending upon the material used but thick enough to retain the cold. There must be no rough edges or loose threads. The size of the compress should be sufficient to cover the closed eyelids and extend over the cheek but not over the brow in order not to congest the eyeball. Before applying, they should be moistened and arranged on the ice in rows to chill, then used in order. When applied they should be cold and moist, but not moist enough to allow water to run over the cheek. The duration varies. They should be changed every 15 to 30 seconds as after that they are no longer cold, being warmed by heat from the eyelids. When applied over an extended period it is wise to use vaseline to prevent injury to the tissues. Applications of Compresses in Gonorrheal Ophthalmia, Oph- thalmia Neonatorum and Other Acute Infectious Diseases.— Gonorrheal ophthalmia and ophthalmia neonatorum (gonorrheal infection of the new-born infant) are both very serious infections threatening the loss of sight and are highly contagious. The most expert care is necessary to prevent complications and loss of sight and to prevent the spread of the infection to the nurse, to other patients or to the patient's other eye, if not already infected. To protect herself and other patients, the nurse should wear a gown, rubber gloves and goggles to prevent any discharge from spurting into her own eyes when cleansing the lids. The patient should be completely isolated from others and all articles used by and for him should be kept separate from others. The pillow should at all times be protected by a rubber case. During treat- ments a rubber dressing sheet covered with a towel should be TREATMENTS TO THE EYES 651 arranged across the patient's shoulder so as to protect the bed linen, etc. Compresses or pledgets used to cleanse the eyes should never be used a second time. They should be placed immediately in a paper bag and later destroyed by burning. It is wise to handle all soiled compresses, etc., with forceps. All utensils, rubber gloves and other articles used for treatments to the eyes should be sterilized immediately after use. All linen should be disinfected before being sent to the laundry or placed in a separate hamper to be disinfected in the laundry. After sterilizing all the articles used in the treatment and before at- tending to another patient, the nurse should discard gown, gloves, and goggles and thoroughly disinfect her hands. She should at all times avoid touching her face or eyes with her hands. To protect the patient's other eye if uninfected, it should be covered with a Buller's shield. The patient should lie on the affected side, or on his back, always so as to aid drainage from the outer angle of the eye and prevent any discharge from flow- ing over the nose into the other eye. The non-affected eye should be watched closely for symptoms or signs of inflammation. Irrigations of the Conjunctival Sac.—Irrigations are given in various forms of inflammation of the conjunctiva (conjunc- tivitis) for cleansing and antiseptic effects. The conjunctiva is a continuous, thin, transparent layer of mucous membrane lining the eyelids and covering the anterior surface of the eyeball. On account of its exposed condition it is liable to irritation from wind, smoke, dust and foreign bodies, etc., and to infection by microorganisms. The many blood vessels account for the "blood- shot" eye when the conjunctiva is irritated and inflamed. On account of its rich supply of blood vessels, lymphatics, mucous glands and lacrymal ducts, the conjunctiva, when irritated or in- fected, is liable to marked congestion and swelling with a marked increase in secretions so that the lids become tender, edematous, adherent and difficult to separate. (In this condition they are easily injured by unskilful handling.) The part also becomes very sensitive and painful on account of its numerous nerve sup- ply, especially when an ulcer or foreign body, etc., is under the lid. The secretions of the conjunctival sac drain through the lacrymal or tear duct into the nasal cavity. Eversion of the Eyelids.—This is a necessary procedure not only in irrigations of the conjunctival sac but in examinations, in the removal of foreign bodies, and in the application of rem- edies to the conjunctiva and eyeball. It is therefore one of the first procedures a nurse should learn in the treatment of diseases of the eyes. Eversion of the lower lid is quite a simple matter. Eversion of the upper eyelid is more difficult and requires some practice. Student nurses may practice on each other. The fol- lowing directions are taken from a text prepared by the Man- hattan Eye, Ear and Throat Hospital. To Expose the Conjunctiva of the Lower Eyelid:—"Place a 652 THE PRINCIPLES AND PRACTICE OF NURSING finger or thumb upon the lower lid, just below the lashes, and direct the patient to look upward and at the same time press downward with a finger, and the edge of the lid will roll outward, exposing the conjunctival surface." To Expose the Conjunctiva of the Upper Eyelid:—"First direct the patient to look downward without inclining the head forward, and at the same time grasp the lashes of the upper lid between the thumb and forefinger of one hand, and with the other hand place a small pencil, penholder, or applicator hori- zontally along the upper part of the lid. Then draw the lid downward and forward and at the same time press the pencil or applicator downward with the other hand. After practising until it is easy to turn the lid by this method, a finger may be sub- stituted for the pencil and, perhaps, after a time sufficient skill may be acquired so that the lid may be turned with one hand alone without the assistance of the other hand. The nurse may stand either behind the patient or in front. "The majority of the patients when told to look downward will incline the head forward without relatively changing the position of the eyes. It is, therefore, necessary to impress upon the patient that he must turn the eyes downward without moving the head, and, moreover, he must continue to look downward as long as it may be necessary to keep the lid everted, because if the patient looks upward suddenly, even after the lid has been suc- cessfully turned, the lid will be immediately turned back to its natural position. The reason for this will be seen from what we have learned under the anatomy of the eye, that the conjunc- tiva which lines the lid is continuous with that which covers the front of the eyeball, and, therefore, when the eye is turned upward the conjunctiva of the upper lid is also drawn upward, and the tension on the conjunctiva causes the lid to turn inward." Method of Procedure in Irrigation of the Conjunctival Sac.— The articles required are the solution ordered, an irrigator, a basin for the return, cotton pledgets and paper bag. The solutions used are boric acid 2 per cent., or sodium chlorid one dram to a pint. Bichlorid of mercury 1 to 10,000 is some- times ordered but is used with caution. Other disinfectant solu- tions such as formalin 1 to 2000 and potassium permanganate 1 to 5000 are occasionally used in purulent conjunctivitis. Boric acid is most commonly used. It is mildly antiseptic, bland and soothing and may be used quite freely without irritation. The temperature of the solution should be lukewarm. The irrigator used may be absorbent cotton, an eye dropper or sometimes a soft rubber bulb or the undine. The patient should be seated comfortably in a chair or, if in bed, in the dorsal recumbent position with the head turned slightly to the side to be irrigated. When the patient is a small child it may be necessary to wrap him firmly in a sheet in order to keep his hands away from his eyes and prevent resistance to and interference with the treatment, and possible injury to the eyes owing to sudden, violent movements. No treatment to the TREATMENTS TO THE EYES 653 eye should be attempted unless the light is sufficient to see ex- actly what you are doing, but avoid having it shine directly into the sensitive eyes of the patient. The patient's shoulder should be protected with a towel. The nurse, when possible, should stand behind the patient. The patient holds the basin under his chin or to the side of his face and may hold a cotton pledget to direct the return into the basin. (This, however, is not advisable when the discharge is infectious as in gonorrheal ophthalmia.) The head is inclined to the side irrigated, slightly tilted backward and may rest against the nurse when the patient is sitting up. Before irrigating, the lids should be carefully cleansed to remove any secretions or particles of dust adhering to the lashes which would otherwise be carried into the sac. The lids should be gently but well separated with the thumb and fingers of the left hand so that the fluid will reach all parts of the membrane. In separating the lids all pressure on the eyeball is to be avoided —pressure is made on the cheek and brow. In irrigating, just sufficient force to dislodge the secretions should be used. The fluid should always be directed from the inner angle of the eye so that it will flush the sac and remove the secretions from the outer angle of the eye. The fluid and discharge must not be allowed to flow down the lacrymal duct to the nose. This would probably cause irritation and obstruct the duct and when the discharge contained microorganisms would spread the infection. Avoid touching the eye with the irrigator. When the sac has been thoroughly flushed and all secretions are removed the lids should be cleansed and dried. Moisture left on the lids causes evaporation and chilling and predisposes to inflammation and congestion. Irrigation of the Conjunctival Sac in Gonorrheal Ophthalmia, Ophthalmia Neonatorum and Other Acute Infections.—The same vigilance is observed as in the application of compresses to pre- vent the spread of the infection to the nurse and other patients or to the non-affected eye. If, by accident, a drop of pus should spurt into one of the nurse's eyes, immediate steps should be taken to prevent serious consequences. A very short time is sufficient to cause serious damage and neglect may result in loss of sight. The conjunctiva lining the upper and lower lids should be exposed and the sac should be thoroughly irrigated with a solution of bichlorid of mercury 1 to 5000. A few drops of argyrol 25 per cent, or of a 2 per cent, solution of silver nitrate should be instilled into the eye. The other eye should be pro- tected until all danger of infection is passed. In irrigating the eye, to prevent complications, extreme care and gentleness must be used in separating the tense, inflamed and swollen lids. Pressure on the eyeball and injury to the cornea must be avoided. Irrigation must be as thorough as possible. Recovery depends upon the thorough cleansing and removal of the secretion as rapidly as it is formed. Application of Ointments.—Antiseptic or irritant ointments 654 THE PRINCIPLES AND PRACTICE OF NURSING are frequently applied to the eyes in inflammatory diseases of the lids, conjunctiva, or cornea. Method of Application.—The lids must be cleansed of all secre- tions or discharges before the application is made. All scales or crusts should be removed. A solution of borax (about half a teaspoonful in a cupful of hot water) will soften the crusts and aid in cleansing. The ointment may then be applied to the margin of the lids with a glass rod or spatula or with cotton on a tooth-pick or applicator. If intended for the conjunctiva or cornea the ointment may be applied to the everted lower lid or the lids may be slightly separated and the ointment may be placed or wiped off the spatula between the lids. In this way it is introduced into the conjunctival sac. Gentle massage of the lids will help to spread the ointment over the surface of the eyeball. Application of Powders.—Antiseptic and irritant powders such as iodoform and calomel, are dusted into the eye to prevent the action of germs and to stimulate the healing of ulcers of the cornea. It is said that the calomel (HgCl) slowly combines with sodium chlorid (Na CI) in the tears and forms bichlorid of mer- cury (Hg Cl2) and in this way keeps the eye bathed in an anti- septic fluid. Method of Application.—The lids should first be cleansed of all secretions. They are then gently separated. The powder is dusted into the eye with a camel's-hair brush, or from cotton wound on a tooth-pick or applicator. The lids should be closed afterwards. As the powder is irritating, the tears may flow freely. Any excess should be wiped from the cheek or lids. A child must be prevented from rubbing the eyes. Application of Solutions.—Antiseptic, astringent, caustic and disinfectant solutions are painted or brushed on the everted lids in inflammatory diseases of the conjunctiva or applied directly to infected corneal ulcers. Removal of Foreign Bodies from the Eyes.—Foreign bodies such as dust, iron, coal or ashes may be carried into the con- junctival sac or may adhere or become embedded in the cornea. When in the conjunctival sac they usually adhere to the inner surface of the upper lid. A nurse may remove a foreign body from the conjunctival sac by everting the lids and brushing it off with sterile cotton wound around a tooth-pick. Before attempt- ing to do so she should see that her own hands are clean and that the light is good so that she can see exactly what she is doing. After the removal of the foreign body a drop or two of argyrol may be instilled to prevent possible infection. If the foreign substance cannot be removed in this way it is probably embedded in the cornea. A nurse should then never attempt to remove it but should call the assistance of an expert surgeon. Burns of the Eyes.—Burns of the lids are treated by irrigating with boric acid, then drying and applying a bland ointment such as boric acid. When the pain is severe a wet dressing of bicar- bonate of soda solution is soothing and lessens the pain. TREATMENTS TO THE EYES 655 Burns of the conjunctiva and cornea are sometimes caused by boiling water, steam, lime, mortar, acids, powder, or molten metal. The treatment consists in the complete removal of the irritat- ing substance as soon as possible. Solids are removed as foreign bodies. The conjunctival sac is then irrigated with a solution which will neutralize the substance or render it insoluble. Boric acid solution is used to remove lime, mortar and other caustic alkalies. A weak solution of bicarbonate of soda may be used to remove acids. Cold compresses are usually ordered to relieve inflammation and prevent swelling and pain. Atropin is used as a sedative and to dilate the pupil. A bandage is sometimes used to protect the eye. Care of Artificial or Glass Eyes.—An artificial eye worn by a patient should be washed frequently and should be removed every night. Patients frequently do this for themselves but it is important for a nurse to know the proper method of procedure. The following instructions are taken from the text prepared by the Manhattan Eye, Ear and Throat Hospital. To Insert the Eye:—"Place the left hand flat upon the fore- head, and with the tips of the two middle fingers raise the upper eyelid. With the right hand push the edge of the artificial eye beneath the upper lid, which may now be released by the fingers and allowed to drop upon the eye. The latter must then be sup- ported by the fingers of the left hand, while with the right hand the lower lid is drawn forward and made to secure the lower edge of the shell, thus holding it firmly in place." To Remove the Eye:—"Draw down the lower lid with the middle finger of the left hand. Then, with the right hand, place the end of a small blunt instrument under the edge of the arti- ficial eye, which is made to slip forward over the lower lid, when it will readily drop out. This maneuver must be carried out with care, as the eye can very easily be destroyed by dropping on a hard surface." The eye should be put away carefully for safe keeping and to avoid breakage or roughening of its surface. The eye socket should be watched for signs of irritation or in- flammation. In some cases mucus and tears are apt to collect between the stump and the shell. It is said that after a year the surface and edges of the eye become roughened so that it must be replaced by a new one to avoid irritation. TREATMENTS TO THE EAR The importance of the function of the ear and its intimate relation to the mastoid cells, dura mater, lateral sinus, and the brain all emphasize the dangers in diseases of the ear and the importance of knowledge, skill, and expert care in the treatments and nursing care. The duties of a nurse may be to assist the surgeon with exam- inations, to apply remedies such as ointments, dressings, and hot or cold applications to the external ear; to irrigate the auditory 656 THE PRINCIPLES AND PRACTICE OF NURSING canal in diseases of the canal or middle ear, and to assist the surgeon with minor operations such as a myringotomy, the in- cision of furuncles, and the removal of wax or foreign bodies. In order to recognize the symptoms of complications and to perform the above duties intelligently, one must have constantly in mind the anatomy and physiology of the ear, the disease from which the patient is suffering, the possible complications, the dangers and discomforts in the treatment, and how to secure the best results with the least discomfort or danger to the patient. To Assist the Surgeon with an Aural Examination.—As in an examination of the eyes, the chief duties of the nurse are to place the patient and the light in the proper position, and provide the necessary articles. The articles required for the examination will be a head mir- ror, ear specula of various sizes, an attic probe (a fine silver probe, tapering to the size of a pin, with a small rounded end, which can be bent in any direction), curettes, a pair of ear for- ceps, an applicator and sterile absorbent cotton, alcohol and hydrogen peroxid. A tongue depressor and a nasal speculum will also be needed to detect the presence of adenoids or enlarged tonsils which are frequently the cause of diseases of the ear. Ear specula should always be warmed before use, otherwise they may cause dizziness and earache. The Position of the Patient.—The light and its position are most important. No treatment or examination should be at- tempted without a good light. The patient may be allowed to sit up on a chair or the examination may be made with the patient lying down. In either case, he should be turned, or his head should be turned so that the ear to be examined is toward the examiner and away from the light. The position of the patient should be comfortable, not strained, neither should it require any effort or strain on the part of the examiner. Daylight from a northern exposure gives the best light, direct sunlight being too dazzling. Artificial light may be used. It should be placed or held behind the patient's head, on a level with the ear, on the side corresponding to the surgeon's mirror, so that the light will strike the mirror at an angle of about forty-five degrees, and be reflected into the external auditory canal. A towel is placed across the patient's shoulders and the head is also draped with a folded towel. The surgeon places his hand on the head to steady it in the desired position; the necessary instruments, etc., are placed conveniently for the surgeon, the nurse assisting him as required. The nurse should stand behind the patient ready to support his head, which is usually inclined slightly away from the exam- iner. It is necessary that the head should be kept perfectly still, to allow a thorough examination, and also to prevent injury with the speculum by a sudden jerk of the head. The ear may be extremely sensitive, the patient may be very nervous from TREATMENTS TO THE EAR 657 prolonged pain so that the insertion of the speculum may cause considerable discomfort. If the patient to be examined is a child he may be held as shown in Figure 151. The Application of Dressings.—Ointments such as zinc oxid, Lassar's paste, or ammoniated mercurial ointment, are used Fig. 151.—Showing Method of Holding a Child for an Examination of the Ears. chiefly in the relief of eczema. Eczema may involve the audi- tory canal, the auricle, the face and the scalp. When the scalp is involved the part should be shaved. All crusts and scales are softened and removed by the application of olive oil before applying the ointment. Pledgets of cotton saturated with olive oil are used in the auditory canal or sometimes hydrogen peroxid 658 THE PRINCIPLES AND PRACTICE OF NURSING is used to soften and dissolve the crusts and scales. In the case of children a tight-fitting cap of light material should be worn, in order to avoid picking and scratching. Moist dressings of cooling and soothing lotions such as lead and opium, aluminium acetate, or plumbi acetate are used in the treatment of dermatitis, perichondritis, and other inflammatory diseases, and following minor operations such as a myringotomy (incision in the drum membrane), or incision of a furuncle in the aural canal. Irrigation of the Ear.—Purpose of the Treatment.—This treatment is necessary in inflammatory diseases of the middle ear or auditory canal for the purpose of removing discharges and relieving the inflammation and congestion. Anatomical Factors to be Considered When Irrigating the Ear. —The auditory canal in the adult is about l1/^ inches in length, Fig. 152.—Showing Method of Restraining a Child for an Examina- tion or Dressing. (From "Nursing in Diseases of the Eye, Nose and Throat," by the Manhattan Eye, Ear and Throat Hospital. W. B. Saunders Co., Publishers.) its outer third being cartilaginous, the inner two-thirds of bone. It is separated from the middle ear chamber by the tympanic or drum membrane. In the infant, the canal is mostly cartilagi- nous and nearly straight, but, because the drum membrane at the end of the canal is oblique, the floor of the canal is in contact with it. In irrigating, to draw them apart, so that the fluid will reach all parts, the auricle is drawn gently downward and back- ward. In the adult, the canal is curved, resembling the letter S. This is because "in passing from without inward the outer por- tion slopes upward, the inner part downward so that the center of the canal is the highest point of an upward convexity. Fur- thermore the outer part inclines sharply forward and then bends backward, while the bony or inner portion inclines gently for- ward again. Hence in the adult, to straighten the canal"—the auricle "is pulled upward to straighten the upward curve and backward to straighten the anteroposterior curves." (Woolsey.) The Method of Procedure.—The articles required will be the solution ordered, the irrigator, a towel to cover the shoulder, an applicator, sterile cotton, and a basin for the return. The irri- TREATMENTS TO THE EAR 659 gator may be a soft rubber bulb syringe or an irrigating can, tubing and tip. The rubber bulb or irrigating tip used for irrigating must be sterile before use, and cleansed, and sterilized after use. The treatment must not be attempted without a good light. The solutions used are cleansing and antiseptic solutions such as boric acid, normal salt solution, bichlorid of mercury 1: 5000 to 1: 10,000 or chlorozene 1: 5000, etc. Bichlorid of mercury is usually contraindicated in acute cases, as it tends to excoriate the skin, cause sloughing, and prevent healing. The temperature of the solution should be such as to give a sensation of comfort. It may vary from 106° to 112°. Never use a solution which feels cool to the patient as, in a sensitive ear, this may cause a severe earache which may last for hours, giving the patient no rest. During the irrigation, the flow should be gentle, steady and continuous. There should be no air in the bulb and no air bubbles forced into the canal. These produce loud sounds like explo- sions and cause great discomfort to the patient. The stream should be gentle, with very little force, to avoid the danger of injuring the drum and, also, to avoid the danger of causing dizziness and faintness in the patient. The flow of hot solution should be continuous to avoid sudden chilling during the inter- vals, due to the evaporation of moisture in the ear in contact with the air. This causes great discomfort, a sensation of cold- ness, dizziness and, sometimes, nausea. When the small rubber bulb is used as the irrigator, it is wise to use two so that one will be filling while the other is in use. The tip of the syringe should be placed at the opening of the canal or barely within so as not to block the passage of the return flow. The basin for the return is held just below the auricle against the neck. Usually the patient can hold the basin, but the nurse should see that it is not tilted, allowing an overflow, and that the patient's fingers are not contaminated. The discharge may contain very virulent organisms. When straightening the canal, do not grasp and pull on the tip but take firm but gentle hold of the cartilag- inous portion of the auricle. When the canal is thoroughly cleansed, it should be carefully dried with sterile cotton. When using an applicator it is im- portant that it should be properly and securely protected with cotton both to avoid injury to the delicate tissues and to prevent the cotton from slipping and being left in the ear. The treat- ments may be given every two or every four hours. A piece of sterile absorbent cotton should be left in the ear between the treatments, to prevent the discharge from running over the auricle and excoriating the skin. The cotton should be changed fre- quently, or when soiled. When soiled, it no longer serves its purpose and may act as a plug. With children it is wise to have them wear a tight, but thin cap, to prevent them from pulling out the cotton and from contaminating their fingers. 660 THE PRINCIPLES AND PRACTICE OF NURSING In charting, note the amount and character of the discharge. Note, also, whether the treatment caused nausea, dizziness or any other discomfort. Myringotomy.—A myringotomy is an incision into the drum for the purpose of providing a channel for the drainage of fluid or pus from the middle ear. It is performed when the drum is red and bulging as this indicates the accumulation and pressure of fluid resulting from otitis media. This minor operation is performed by the surgeon. The duties of the nurse are to prepare the patient and the articles required. Preparation of the Patient.—The patient should be in bed, lying on his side, close to the side of the bed, and with the ear to be operated upon uppermost. A general anesthetic is nearly always given because the ear is so very sensitive and painful and even the slightest movement might result in a very serious accident. Nitrous oxid gas is commonly used. Frequently no anesthetic is given to very young babies. They may be wrapped firmly in a sheet and the head may be held quite still by the nurse. When the surgeon is ready to begin, sterile towels should be placed across the shoulder and around the head, covering the hair. In some hospitals a square made of several thicknesses of gauze with an opening or slit large enough to expose the ear is used for draping. This covers the neck, side of the face and head and so renders the area around the ear sterile. These squares may be used when examining the ears; when used for this purpose they are not sterile. The articles required will be a myringotomy knife (myringo- tome), ear specula, ear forceps, an applicator, sterile cotton, sterile cotton tooth-picks, hydrogen peroxid and alcohol. Glass slides will be required if smears are to be made from the dis- charge. All the instruments used should be sterile. The my- ringotomy knife is sterilized by immersion in 70 per cent, alcohol. It must never be allowed to come in contact with a hard surface and should not be wrapped in cotton as this dulls the blade. The examiner may require sterile rubber gloves. Some surgeons irrigate the canal directly after the incision is made for the purpose of washing out any blood-clots which, if allowed to remain, might block the incision. Some surgeons apply a moist dressing after the operation to absorb the discharge. When these are required the necessary things should be in readiness. A good light is absolutely essential. It should be placed so that it will be reflected by the doctor's head mirror into the pa- tient's ear. After a myringotomy the canal is usually irrigated every two or three hours, according to the amount of the discharge. Sterile cotton is kept in the canal between treatments. Incision of Furuncles in the Aural Canal.—The preparation of the patient is much the same as for a myringotomy. A gen- eral anesthetic is usually given but sometimes the patient is allowed to sit up in a chair and the canal is anesthetized with cocain. TREATMENTS TO THE EAR 661 The articles and instruments required are also much the same. These consist of sterile towels for draping; sterile cotton and antiseptic solutions such as alcohol, hydrogen peroxid and car- bolic acid for cleansing the canal; sterile instruments such as ear specula, furuncle knife, ear forceps, curettes, scissors, appli- cator, probe, director, and basin for soiled instruments. Some- times the canal is irrigated after the furuncle is incised and sometimes it is packed with plain gauze packing saturated with an antiseptic solution such as carbolic acid 1 per cent, to pre- vent further infection and formation of furuncles. Carbolic also acts as a local anesthetic. The after-care varies. Usually a large moist dressing is applied. The solution used may be cool- ing and soothing, such as aluminium acetate, or it may be an antiseptic solution such as 1 per cent, carbolic acid. The anti- septic dressing must be kept moist and should be changed fre- quently to prevent the formation of furuncles. The soothing dressing is usually followed by irrigations of the canal with an antiseptic solution, such as boric acid or bichlorid of mercury 1: 10,000, every two hours. Sterile cotton is kept in the canal between treatments. In the treatments of furunculosis, attention to the general health is very important. The condition is more apt to recur in anemic or diabetic patients. Tonics, fresh air, and careful regulation of the diet are, therefore, essential. The injection of vaccines, either autogenous or stock vaccines (staphylococcus) sometimes builds up the patient's resistance and prevents a recur- rence of the infection. Removal of Cerumen (ear wax) and Epithelial Plugs (Dan- druff).—Ear wax or scales of epithelium may collect in the auditory canal and completely obstruct the passage or may become caked against the drum membrane. The result may be deafness, a sense of fullness, dizziness, sometimes pain, and a reflex cough. The reflex cough is due to an irritation of Arnold's nerve, a branch of the pneumogastric nerve which supplies the lungs. Epileptic attacks have been caused by the presence of hardened wax in the auditory canal. Irritation, inflammation and ulceration may occur if the hardened wax is not removed. Cerumen is more apt to collect in aged persons because the exter- nal meatus becomes flattened. The treatment consists in softening the mass and removing it by syringing. Sometimes instruments are necessary to remove it, but this should be attempted only by an expert person. A nurse should never attempt to do so. Frequently, before syring- ing, it is necessary to soften the hardened cerumen or epithelial plug by the instillation of drops. A solution commonly used for this purpose consists of bicarbonate of soda gr. xxv; glycer- ine, 5 i and aqua, § i. When the wax is very hard the instilla- tions may have to be repeated several times a day for several days before it can be removed by syringing. Frequently it is only necessary to allow the drops to remain for about fifteen minutes before syringing. The patient should be allowed to lie 662 THE PRINCIPLES AND PRACTICE OF NURSING down in the interval. Instillations of warm hydrogen peroxid are also commonly used and allowed to remain in the ear for five or ten minutes before syringing. The solution used for irrigating is usually bicarbonate of soda 5 i to a pint of warm water. The syringe used may be the small rubber aural syringe, but is usually the large metal Pomeroy or the Neumann ear syringe. These metal syringes are heavy, difficult to handle without injury to the ear and to manipulate so as to secure a steady, continuous stream with little force. Considerable practice is necessary before these syringes can be used with safety or skill. Therefore, in some hospitals where it is impossible for all the pupil nurses to have sufficient practice they are not allowed to use these metal syringes. A good light is essential for this procedure. The surgeon must direct the stream of solution between the wax and the canal at different points so as to separate it and force it outward. After removal of the wax or epithelial plug, the canal is care- fully dried and the ear is usually inflated because the drum is often found retracted. Absorbent cotton is then placed in the meatus, and allowed to remain for the rest of the day. The metal syringe is easily cleansed and sterilized as it can be taken apart. Removal of Foreign Bodies from the Auditory Canal.—A surgeon will always carefully inspect the canal before attempt- ing to remove a foreign body. It may usually be removed by persistent syringing with warm water. No other method should ever be attempted by a nurse. Instruments are sometimes neces- sary but should be used only by a skilled otologist. In the hands of an unskilled person an instrument may push the foreign body farther into the canal or may cause such irritation, inflam- mation and swelling, that an operation under a general anesthetic is necessary to remove it. (An incision behind the ear into the canal is made.) Gravity, that is, inclining the patient's head toward the affected side, is helpful and in children, in whom the canal is straight, rotation with the finger in front of the ear is sometimes helpful in causing a round, smooth body to work its way outward. When syringing the ear, the patient's head should be inclined toward the affected side. The auricle should be held upward and backward and the stream directed between the foreign body and the canal. If the foreign body is a seed and the water does not remove it, but causes it to swell, the canal may be syringed with alcohol. Alcohol absorbs the water, prevents swelling, and may cause the seed to shrink. The instillation of oil or glycerine before syringing aids in the removal of seeds. When the foreign body is an insect, syringing with water stimulates it and causes great discomfort to the patient. The instillation of oil or a drop or two of chloroform kills insects, after which they may easily be removed by syringing. The ear should be carefully TREATMENTS TO THE NOSE AND THROAT 663 dried afterward and absorbent cotton left in the meatus to pre- vent chilling and earache. Symptoms to be Watched for when Nursing Patients with Otitis Media.—The danger of serious complications in purulent otitis media should always be remembered and the symptoms constantly watched for. Such symptoms as the following should be reported to the surgeon immediately;—a chill and sudden rise in temperature, dizziness, nausea, vomiting, nystagmus, in- tense headache, pain or tenderness, stiffness of the neck or re- traction of the head, delirium, drowsiness, stupor, or coma. These may indicate acute mastoiditis, inflammation of the in- ternal ear, meningitis, perisinus abscess, epidural or brain ab- scess, and septicemia or pyemia. TREATMENTS TO THE NOSE AND THROAT The duties of a nurse may be to assist the doctor with exami- nations, to apply remedies in the form of sprays and inhalations, to give nasal and throat irrigations and to assist the doctor with an intubation or a tracheotomy. The intimate relation of the nose to the eyes, ears, throat, the various sinuses of the head and the brain; the delicacy and vas- cularity of its mucous lining and the spongy character of its bony structure; the frequency with which it forms a lodging place and portal of entrance for virulent, pathogenic germs and the relation of the nose and throat to the lung, a vital organ, all emphasize the dangers in diseases of the upper respiratory tract and the need for knowledge, skill and expert care in the treatments and nursing care. To carry out the above duties intelligently, and to secure the best results with the least discomfort and danger to the patient, one must have constantly in mind the anatomy and physiology of the part, the disease from which the patient is suffering, the possible complications, the dangers and discomforts in the treat- ment, and how best to avoid them and secure the desired results. To Assist the Doctor with an Examination of the Nose and Throat.—For these examinations, the patient should be seated on a chair, preferably a high-backed chair, so that his head may rest against the back of the chair. The examiner sits facing the patient on an adjustable stool arranged so that his head will be on a level or a little above that of the patient. A reflected light is always used, that is, a light which is reflected from a head mirror, worn by the doctor, into the part examined. The doctor wears the head mirror on the left side so that the light must be on the right side of the patient on a level with his ear and a little behind the transverse axis uniting the ears. The exami- nation may be made in daylight but artificial light is usually used—it must be adjustable to the height of the patient. A towel covers the patient's shoulders. 664 THE PRINCIPLES AND PRACTICE OF NURSING When the patient to be examined is a child he may be held as shown in figure 153. The instruments required for the examination of the anterior part of the nose will be nasal specula, nasal forceps, a probe, an applicator and sterile absorbent cotton. As the nasal mucous Fig. 153.—Showing Method of Restraining a Child for an Examination of the Throat. membrane is very sensitive and sometimes so swollen as to make the examination difficult, cocain hydrochlorate is frequently sprayed from a hand atomizer or painted over the part to an- esthetize the part and reduce the swelling. for an examination of the nasopharynx and posterior struc- tures of the nose, in addition will be required a tongue depressor TREATMENTS TO THE NOSE AND THROAT 665 and a small throat mirror which is placed at the back of the mouth to reflect the light into the nasopharynx. All mirrors used for examination should be warmed. An alcohol lamp will be required so that the mirror may be warmed in the flame. For an examination of the larynx a laryngeal mirror and a napkin or several thicknesses of folded gauze with which the doctor grasps and pulls forward the tongue will be needed. The instruments used for examinations should be sterilized by boiling. After use and before using for another patient they should be resterilized, preferably by boiling or by immersion in carbolic acid solution 1:20. Before using the instrument again this strong solution should be rinsed off with carbolic solution 1:100 to avoid burning the patient. These solutions should be changed frequently. Laryngeal mirrors are soon destroyed by boiling so are sterilized by immersion in a carbolic solution. In the examination of patients with a primary or secondary syphilitic lesion in the nose or throat, the doctor usually pro- tects his hands with gloves. There should be a separate set of instruments for these patients, if possible, and in any case, after use they should be kept separate and immediately sterilized by boiling or placed in carbolic 1:20 solution and boiled later. If a number of patients are being examined these are left until the last. In the examination of patients with tuberculous lesions the same precautions as to the use of the instruments and the order of examination should be observed. If these precautions are not strictly observed these serious and highly contagious diseases may be transferred to other patients. Sprays are used in acute or chronic inflammation and in ulcer- ation of the lining of the nose or throat. They may be applied to the mucous lining of the nose or throat by means of a hand atomizer. The solution is forced out through the perforated tip by increased pressure of air made by squeezing the rubber bulb attached. An instrument should be used which gives a generous stream as a very fine spray is apt to injure the tissues. A force- ful spray is also very injurious to the tissues. The solutions used vary according to the condition and the results desired. They should always be ordered by the doctor. All solutions used should be warmed to a temperature of 100° F. If the solution causes pain it is too strong and this fact should be reported to the doctor, who will probably dilute it. Method of Application.—A spray is frequently administered by the patient himself but the nurse should see that it is prop- erly applied. When applied to the nose the tip of the nostril should be raised and the tip of the atomizer placed just within the nostril. If introduced too far it may injure the septum. Very little force should be used. Greater force may be used when applied to the throat. If possible there should be sepa- rate tips for watery and oily sprays. After using a watery spray, patients should not be allowed to go out immediately into 666 THE PRINCIPLES AND PRACTICE OF NURSING the cold as they are very apt to catch more cold and increase the inflammation. Gargles are used in the same conditions of the throat in which sprays are used. The solutions used may be cleansing or anti- septic, etc., and are used either hot or cold. The patient must be cautioned against either swallowing or inhaling the solution. The rigid control of the throat and breathing necessary in gargling is very difficult to the already sensitive throat so the solution may fail to reach all parts of the inflamed mucous lining. For this reason some doctors prefer sprays which may be directed to the diseased part. Throat Irrigation.—A throat irrigation is used for inflamma- tory diseases of the throat or tonsils, such as pharyngitis, ton- sillitis, scarlet fever, and diphtheria. The irrigation is a direct application of moist heat to the mucous lining of the throat. Purposes and Effects of the Irrigation.—This treatment is given for the following reasons:—(1) To soften mucus and to remove accumulated secretions and discharges; (2) to stimulate the circulation and cause the absorption of inflammatory prod- ucts; (3) to relieve congestion, swelling and pain and to pro- mote healing; (4) to stimulate the inflammatory process (sup- puration) and "bring to a head" as in quinsy so that the abscess may be incised and the pus removed. The solutions used are varied and may be plain hot water, normal saline or water with bicarbonate of soda o i to a quart. The temperature is ordered (may be 100° to 120° F.) but is usually as hot as the tissues will stand but should not be more than 118° to 120° F. The sensations of the patient are not always a safe guide because when in great pain or discomfort a very hot solution may give great temporary relief and at the same time burn the tissues. The continued use of moist heat also softens and relaxes the tissues and paralyzes the blood vessels, lowering their resistance and interfering with their subsequent healing. The results of this treatment depend upon the temperature of the solution and the way in which it is given. To obtain the de- sired results a continuous stream must reach the parts affected without causing the patient to gag, thus forcing him to swallow or aspirate the solution. A patient frequently prefers to give this treatment himself and, when up and walking around, the doctor may permit him to do so. The nurse then prepares the treatment, gives any as- sistance or instructions necessary and sees that the treatment is satisfactorily given. Method of Procedure.—The articles required will be an irri- gating pole, irrigating can, tubing with clamp, a sterile irrigat- ing tip, the solution, a large pail or basin for the return, protec- tion for the chest and shoulder of the patient and, when given in bed, for the bed. When the patient is in bed there are two methods of procedure sometimes used—some doctors and patients prefer one, some the TREATMENTS TO THE NOSE AND THROAT 667 other. In one method, the patient lies across the bed, in a com- fortable position, so that his head hangs over a pail which rests on the floor and the patient himself directs the stream against the part affected. The nurse adjusts the apparatus, regulates the flow of the stream and may support the patient's head. In this method the patient can usually control the position of his tongue better so that it does not obstruct the flow and the stream can be directed farther back to all the diseased part without causing gagging or coughing or the danger of swallowing it. In the second method the patient sits up in bed, at the side, supported with pillows and with his head bending forward over a basin. The nurse manipulates the tubing and tip and directs the stream upon the parts affected. It is absolutely essential, therefore, that she should see what she is doing. Before beginning the irrigation she should carefully examine the throat. To do this, the tongue must be depressed with a tongue depressor as it obstructs the view and very few patients can keep the tongue down for a sufficient time. A wooden tongue depressor may be used and destroyed after use. If the tongue depressor is not properly used it will so displace the tongue as to further obstruct the view and the stream, making the treat- ment useless. It must be remembered that the space for the tongue is limited. Placing the tongue depressor too far forward on the tongue depresses the anterior part, causing the posterior part to rise, thus obstructing the view. Placing it too far back pushes the tongue backward and this produces gagging which, once excited, is repeated with further attempts to depress the tongue as the pharynx is so very sensitive. This is a procedure a nurse may frequently have occasion to use, the success of a treatment depends upon it, and it is im- portant that it should be correctly and skilfully done. Dr. Coakley gives the following rules to be observed:—The mouth should be opened nearly to the full extent. The patient should be told to allow the tongue to rest within the mouth. (Many patients as soon as they open their mouths protrude the tongue.) Attempts at depression with the tongue protruded result in in- jury to the tongue and spasm of the organ, with insufficient depression. If one carefully observes the tongue while lying quietly within the opened mouth, he will see that it is arched from before backward. Pass the depressor into the mouth care- fully, avoiding touching any of the tissues, particularly the upper surface of the tongue, until the tip of the tongue depressor passes about one-eighth of an inch beyond the highest point in the arch of the tongue, then gradually lower the depressor and make gentle, steady pressure upon the organ. Do not slide the tongue depressor over the surface of the tongue; that of itself is often sufficient irritation to cause reflex gagging. Keep the tongue depressor in the median line. Pressure to one side or the other crowds the tongue so much to the opposite side as often to cause gagging. Avoid using too great pressure, for in so 668 THE PRINCIPLES AND PRACTICE OF NURSING doing there is insufficient space along the floor of the mouth for the depressed tongue, and it is again forced backward, with the inevitable gag. With the tongue depressor in position and the tissues in view the nurse directs the stream. The patient's head should be turned toward the light and bent sufficiently forward to allow the return to flow into the basin and to prevent the possibility of the discharge being swallowed—gagging will surely cause this, so stop if the patient gags, coughs or chokes. When satisfied with the results discontinue the treatment. Do not continue long enough to exhaust or tire the patient. Usually one quart of solution is used. Whatever method is used, the bed and patient should be pro- tected. This treatment usually gives great comfort and relief and when the patient objects it is frequently because it is not prop- erly given. The treatment and its results are charted. Inhalations.—Inhalations, or the administration of medica- tions by inhaling, may be dry or moist. Dry inhalations are frequently used in the form of "smelling salts," in which the medications are contained in a tightly corked bottle, the cork being removed only when in use. They contain drugs which increase the secretions (expectorants), such as am- monium chlorid, ammonium carbonate, tincture of benzoin comp. (which is also antiseptic), and carbolic acid, which is an anti- septic and local anesthetic. Moist or steam inhalations may be plain or medicated. They are used (1) to relieve inflammation of the mucous mem- brane in acute colds and in sinusitis, (2) to relieve inflammation, congestion and edema of the larynx, (3) to loosen the secretions and relieve coughing in tuberculous laryngitis, and in membran- ous laryngitis, (4) to soften thick, tenacious mucus in chronic laryngitis, (5) to warm and moisten the air following opera- tions on the larynx such as a tracheotomy when the air passes directly to the larynx through the tube instead of through the nose and, (6) in acute bronchitis and whooping-cough the steam allays the irritation by moistening the air. It checks coughing and aids the action of the drugs. The inspired air is carried to and benefits the farthest bronchioles and vesicles of the lungs. Volatile substances are frequently added to the water, which is kept at a temperature of 150° F., the steam from which is directed toward the nose and mouth of the patient so that the moistened air and drug may be inhaled and come in contact with the inflamed tissue. Antiseptics such as tincture of benzoin 3 i to a pint, oil of turpentine, menthol, creosote, oil of eucalyptol and other drugs are used. Oil of turpentine and tincture of ben- zoin also loosen and increase the secretions and relieve coughing. Method of Procedure.—Various inhalers are used. The medi- cated solution may be poured into a narrow-necked pitcher over the mouth of which should be placed a cone of cardboard or oiled TREATMENTS TO THE NOSE AND THROAT 669 paper which directs the steam toward the mouth of the patient. An ordinary tea-kettle may be used in the same way. The Maw's inhaler, made of earthenware, is frequently used as it re- tains the heat for a considerable time. The "croup kettle"—a tin kettle with a long spout to which the cone may be attached —is commonly used in the hospital. When available, an elec- tric stove is the best and safest means of keeping the solution hot. When it is desirable to have the patient breathe warm, moist air continuously or for a prolonged period without the effort, strain and discomfort of keeping the face turned constantly toward the inhaler (even during sleep) which is very exhausting, or if in the case of a child with croup a "croup tent" should be arranged around and over the head of the bed. The outer cov- ering of the tent may be of linen but the inner lining must be of blanket in order to absorb the moisture and to prevent the condensed steam from falling on the patient or bed. The head of the bed must be securely enclosed so that the steam will not escape. There should be ample ventilation, however, and the tent "should not be kept so warm that both patient and nurse get a steam bath." There must be no drafts. The kettle should be on a table or chair, the spout extending into the tent at the side or back but it must not extend far enough for the patient to touch it, or over the patient in order to avoid the condensed steam falling on and scalding him. He must be watched closely. In whatever method used, great care must be taken that the steam is not too hot and that it does not scald the patient. Great care also must be taken to protect the patient from drafts and he must not be allowed to go out of doors for several hours as the relaxation of the mucous membrane and blood vessels makes a patient very susceptible to the cold and predisposes to a more severe and prolonged attack of inflammation and congestion. Nasal irrigations are used in the treatment of rhinitis and sinusitis. They should be given with extreme care by an expe- rienced person and oniy when ordered by a doctor. The purpose of the treatment is to soften and remove mucus, dried secretions, crusts, pus and other discharges and to relieve congestion, swelling and pain. The solutions ordered may be plain hot water, normal saline or bicarbonate of soda solution. When the odor from crusts is very foul, as in atrophic rhinitis, a solution of potassium per- manganate may be ordered as a deodorant. The temperature varies from 105° to 110°—the hotter the better as the heat draws out the pus. Method of Procedure.—The danger of forcing the discharge and spreading the infection to the throat and up the Eustachian tube to the middle ear, causing otitis media and thus predis- posing to other serious complications which may occur, should be kept constantly in mind. The aim is to cause a copious, 670 THE PRINCIPLES AND PRACTICE OF NURSING gentle and uniform stream of solution to pass up one nostril, back into the nasopharynx, around the septum, and out of the other nostril. Preparation of the Patient.—The treatment may be given, if necessary, with the patient in bed lying on his side close to the edge of the bed. It is best given with the patient sitting up in a chair bending over a sink or basin. The head should be well flexed on the chest. A towel or sheet may be used to drape the patient. The articles used vary with the method. The irrigation may be given with a Douglass syringe or with a douche bag or can, rubber tubing and nasal irrigating tip, and basin for the return. During the procedure the patient must sit with his head bent forward and his mouth open. He should be instructed to breathe through his mouth. He should also be instructed not to swallow as this depresses the palate muscles and opens the Eustachian tubes. The irrigating tip or nozzle should be inserted in the nostril just tightly enough to prevent the return of fluid from that nostril. The irrigator should be held just high enough (usually not more than 2 or 3 inches above the level of the patient's nose) to cause a gentle, steady stream of fluid to flow out the other nostril. Force or pressure should never be used as it would probably force some of the discharge up the Eustachian tubes. The flow should be checked if the patient coughs or chokes as this opens the Eustachian tubes and indicates that the solution is not returning properly, due to some obstruction. Some au- thorities state that the stream should be first directed up the unaffected side. This washes out the discharge from the affected side without the danger of forcing it up the Eustachian tube or spreading the infection to the unaffected side. Other authorities advise syringing through the obstructed side. In this method the unobstructed nostril allows free passage for the exudate. A sufficient amount of solution is used to thoroughly cleanse the nostrils. Patients should be warned not to blow excess fluid from the nose for several minutes after the procedure as this act may force discharges into the Eustachian tubes and middle ear. They should not be allowed to go out in the cold for at least half an hour as the hot irrigation and increased blood sup- ply in the mucous lining predispose to colds. In charting the procedure the amount of solution used, the character of the return and any symptoms of middle ear dis- turbance such as a sensation of water in the ears, should be noted. An intubation consists of the introduction of a hard rubber or gold-plated metal tube into the glottis for the purpose of keeping the normal respiratory channel sufficiently open to allow the patient to breathe until such times as the obstruction to breathing may be removed. It is indicated whenever an obstruction to breathing causes TREATMENTS TO THE NOSE AND THROAT 671 marked dyspnea, producing cyanosis and exhaustion of the pa- tient in the effort to breathe. It is frequently required in diph- theria, and in inflammation and edema of the glottis from any cause. The "intubation set" or articles required consists of a mouth gag, an intubator or introducer, an extubator for the removal of the tube and a graded set of hard rubber tubes, corresponding to the age of the patient and size of the larynx, devised by Dr. Joseph O'Dwyer. The tubes are threaded with silk thread and are each attached to an obturator. The Procedure.—The position of the patient is extremely im- portant in order to enable the doctor to insert the tube—the nurse is responsible for the position and the success of the treat- ment largely depends upon it. An adult may be placed hori- zontally on the bed or table with the head held perfectly straight. A child should be wrapped closely and confined in a sheet and should be held upright by the nurse with the child's feet held securely between her knees and with the back of its head resting upon her shoulder. Another assistant should hold the child's head up and backward as far as possible with the chin in a straight line with the trachea. This assistant also holds the mouth gag in place. The doctor sits directly opposite the patient. A good light is essential. The doctor may wear a head mirror from which the light is reflected into the child's throat. Other- wise the child should be held so that the light from a window or artificial light will shine directly in the throat. When the tube is first inserted there will be a good deal of mucus secreted—hold the child's head to one side to allow this to escape. If the tube is properly in the larynx one or two coughs will be given. The breathing which before was croupy becomes quiet. The color improves, cyanosis disappears and the child, almost worn out with his struggles, usually falls asleep. If the tube is in the esophagus, instead of the larynx, coughing will not occur, the color and breathing will not improve and the string, attached to the tube and left hanging from the mouth, will be seen to gradually recede due to the peristaltic action of the muscles of the esophagus. The silk should be left hanging and observed carefully for about 10 minutes. It is then either removed or tied around the ear and fastened to the cheek with adhesive. One objection to the silk is that it is possible for a child to reach it and pull it out. When the silk thread is re- moved from the tube after it is inserted into the larynx, there is said to be no danger of the tube entering the trachea because the whole tendency is to cough the tube up and out. It may, however, enter the esophagus. The insertion of the tube should take only about 2 or 3 seconds and should not last more than 15 seconds as during the intro- duction the breathing is obstructed. The child should be con- stantly and very carefully watched. The best method of feeding the child is by nasal gavage. Pre- 672 THE PRINCIPLES AND PRACTICE OF NURSING caution must be taken to see that the catheter is in the esophagus. Great care must be taken to avoid liquid entering the tube as this would strangle and produce coughing. Coughing may expel the tube and the child may die of asphyxia. When nasal feeding is not used hold the child's head much lower than the body and feed liquids with a spoon. Rectal feedings will have to be re- sorted to if there is difficulty of feeding without the liquid enter- ing the tube and causing coughing. The tube is usually left in for from 2 to 7 days; in diphtheria, usually about 5 days, depending upon the rapidity with which the membrane is absorbed. The position of the patient for the removal of the tube is the same as for the introduction. After its removal the physician usually waits and watches the patient, for at least one hour, for swelling of the parts and renewed difficulty in breathing. A tracheotomy consists of a vertical incision made into the trachea and the insertion of a double tracheotomy tube through which the patient breathes. It is indicated when it is difficult or impossible for the patient to breathe through the larynx due to some obstruction to res- piration which cannot be overcome by an intubation or other means and the patient is in danger of asphyxiation or exhaus- tion from his efforts to breathe. 1. In acute inflammation with urgent dyspnea as in laryngeal diphtheria or croup when not relieved by an intubation. 2. In edema of the glottis which causes dyspnea, hoarseness and a croupy cough. The submucous tissue above the glottis is very loose and may swell very rapidly in acute laryngitis, etc., obstructing the glottis and endangering the life of the patient from asphyxiation. 3. In Bright's disease with general edema, including edema of the glottis. 4. In tuberculosis of the larynx with inflammation and edema. 5. With malignant growths such as carcinoma of the esoph- agus. The cartilaginous rings of the trachea are completed at the back, where it is in contact with the esophagus, by soft mus- cular tissue so that carcinoma of the esophagus may cause serious difficulty in breathing by pressing on this soft portion of the tracheal wall. 6. With benign tumors. 7. In ulceration and stenosis of the larynx due to syphilis and other causes. 8. In obstruction due to foreign bodies in the larynx or throat. Also, for the purpose of removal, when a foreign body is in the bronchi. 9. In paralysis of the muscles of the vocal cords. The incision into the trachea may be made above or below the isthmus of the thyroid gland. The trachea is partly in the throat and partly in the thorax. The isthmus of the thyroid ex- tends across it at a level with the second or third tracheal ring. TREATMENTS TO THE NOSE AND THROAT 673 When the incision is made above the isthmus, it is called a high tracheotomy, when made below, a low tracheotomy. A high tracheotomy is always performed where possible in preference to a low tracheotomy for the following reasons:— As the trachea descends it passes somewhat backward so that the lower portion is deeper and, therefore, much more difficult to reach. The upper part is quite superficial, therefore more acces- sible. In addition, the dangers involved in a low tracheotomy are much greater because of the large arteries and veins which either cross it above the sternum or are in close relation to it. As these vessels are usually congested when a tracheotomy is indicated, the danger of injury with a fatal hemorrhage may be very great. The danger from bronchopneumonia, which is apt to follow a tracheotomy, is also greater. However, a low tra- cheotomy is sometimes necessary in order to relieve an obstruc- tion low in the trachea or to remove foreign bodies from the bronchi which if not removed, may cause a fatal result. The very greatest care and vigilance, therefore, must be ob- served both during the operation and in the after-care of the patient following a tracheotomy, whether high or low, but par- ticularly when a low incision has been made. The Procedure.—The trachea may have to be opened in an emergency when the patient is already greatly cyanosed, with no consideration for antisepsis or asepsis, and with no instrument available but a pocket penknife—many lives have been saved in this way. Judgment, presence of mind, speed and accuracy are essential so that every nurse should recognize the indications for this treatment and should know instantly what to do. The patient is in immediate great suffering and danger and his life is at stake. When there is time for preparation the following instruments should be brought to the bedside—a scalpel, 2 thumb forceps, a grooved director, 2 sharp tenacula, % doz. artery clamps, 2 re- tractors, needles, catgut and silk for ligatures and sutures, sterile gauze and several double tracheotomy tubes of several sizes and different curvatures. All the instruments must be sterile and the operation performed with strict aseptic precautions. Sterile cot- ton sponges, sterile wipes and a receptacle for the soiled sponges will also be needed. Preparation of the Part.—The part, from the top of the larynx to the sternum, must be very carefully cleansed and disinfected as for a major operation. The Anesthetic.—In severe cases, with dyspnea and cya- nosis, it is said that the patient is so narcotized by the carbon dioxid poisoning as. not to need an anesthetic. Sometimes a local anesthetic, for adults, is used—4 per cent, cocain injected subcutaneously. For children or nervous, hysterical patients a general anesthetic is given. Chloroform is used because much less irritating than ether and because the secretions are increased less than when ether is used. 674 THE PRINCIPLES AND PRACTICE OF NURSING The position of the patient is extremely important. A child should first be wrapped tightly in a sheet to prevent struggling. In all cases the patient should be in the dorsal recumbent posi- tion with a hard pillow or sandbag under the neck so that the head is low and the neck fully extended. This "steadies the trachea, makes it more superficial, lengthens the neck and the portion of the trachea in the neck and makes tense the structures in front" (Woolsey). The head in all cases must be kept per- fectly straight as the incision must be made exactly in the median line. This is particularly important in a low tracheotomy be- cause the common carotid arteries and other arteries are here so close to the sides of the trachea as to render them liable to injury if the position is not maintained, and interferes with the proper incision. The position is also extremely important with children because it is difficult to make the incision satisfac- torily, due to the small size of the trachea (the full length of the cervical portion in a child from 3 to 5 years being only about 1Y2 inches), its depth and mobility and the high level at which the large blood vessels frequently cross it. (Woolsey.) The nurse is responsible for the preparation and the position of the patient. During the procedure, the nurse should stand on the left of the patient ready to assist the surgeon as the need arises. The surgeon stands on the patient's right. When the operation is performed in diphtheria the doctor and nurse usually wear a mask to prevent infection from the spurting of secretions, etc. The incision is first made through the skin and fascia, the muscles being separated (not cut) with retractors. There is sometimes severe hemorrhage due to severing of the congested blood vessels, so the nurse must be prepared with artery clamps and sponges, etc. When the incision (about three-fourths of an inch, at right angles) is made into the trachea there will be a rush of air with spasmodic coughing and considerable blood- streaked mucus with a sudden rising and falling of the trachea. This is allowed to subside before the tracheotomy tubes are in- serted, the trachea being held open with the dilators. The tube used should not be too curved as it is said that the pressure from its sharp end may cause an ulceration into the innominate vein or artery or the common carotid and occasion a fatal hem- orrhage. A number of cases have been reported where this has occurred. Silver tubes are used in preference to hard rubber as they are less irritating. Double tubes are used so that if one should become clogged with mucus it may be removed, cleansed and reinserted. The outer tube is held in place with tape, which is fastened around the neck. This outer tube is never removed by the nurse. A layer of soft sterile gauze is usually inserted be- tween the plate of this metal tube and the skin to prevent irritation. The patient must now breathe through this tube and as he depends entirely upon it the greatest vigilance must be observed TREATMENTS TO THE NOSE AND THROAT 675 in his care. The inspired air, which normally in its passage through the nose is moistened, filtered and warmed to body tem- perature, now passes directly into the trachea and lungs. One of the chief duties of the nurse in the care of the patient will be to artificially warm, moisten and filter the inspired air. Again, the expired air will be laden with increased mucus and particles of diphtheritic membrane or cancerous growth, etc. The patient cannot expectorate this or control it in any way and it all passes through the tube which may thus soon become clogged. As long as there is any danger from clogging of the tube, the pa- tient must be watched constantly, never being left alone. The patient is also apt to be extremely nervous until accustomed to breathing through the tube. He may become very excited with the least difficulty in breathing or clogging of the tube and may in his excitement dislodge the tube and strangle to death. The dangers following this operation may be:—1. The spread of diphtheria to the wound, the trachea and bronchi with bron- chopneumonia, which is usually fatal. 2. Infection of the wound —extreme care must be taken to prevent this. 3. Inhalation of infected matter (pus, etc.), resulting in septic pneumonia, usually fatal. 4. Pneumonia. 5. Shock. 6. Hemorrhage. 7. Displace- ment of the tube with danger of asphyxiation. If displaced, hold the opening apart with forceps or any instrument at hand until the doctor comes. Try to replace the tube but do not use force as this will cause injury to the tissues, which will make it very hard to reinsert the tube later. 8. Abscesses. 9. Emphy- sema of the thorax and tissues of the neck has followed a tracheotomy. The After-care.—To supply the function of the upper respira- tory tract—to moisten, filter and warm the air to body tempera- ture. The temperature of the room should be about 80° F. Steam inhalations, with a croup tent, give great relief by warm- ing and moistening the air. The tent must be well ventilated but there must be no drafts, great care being taken to pre- vent chilling with the danger of contracting pneumonia. While it is desirable to have the air warm and moist it must not be saturated and so hot as to give both patient and nurse a steam bath thus increasing the risk of chilling and pneumonia. Square pieces of gauze dampened with warm sterile water, boric acid or carbolic solution (1 to 60) should be kept over the mouth of the tube to moisten and filter the air. This should be changed as soon as dry or soiled with secretions, etc. Sterile gauze is also used to swab mucus, etc., away from around the tube. There should be no loose threads to the gauze as they might accidentally get into the tube and trachea and strangle the patient. To keep the tube from becoming clogged, thus closing the passage and causing asphyxiation, constant watchfulness will be necessary, especially if there is much secretion from the lungs, etc. The patient must never be left alone if there is danger of 676 THE PRINCIPLES AND PRACTICE OF NURSING the tube becoming clogged and the inner tube must be cleansed as often as necessary. This may be every few minutes or every hour, etc., depending upon the condition. The inner tube may be removed, cleansed and boiled every fifteen minutes, if necessary, and reinserted. When there is con- siderable secretion, it may be necessary to have a second sterile tube to reinsert. Frequently it is unnecessary to remove the inner tube for cleansing. In this case, it should be cleansed with a feather (previously sterilized) and moistened in a salt solu- tion or bicarbonate of soda solution which is alkaline and so readily dissolves and removes the mucus. The nurse must not remove the outer tube nor clean the inner tube with cotton on an applicator as there is great danger of its slipping or being retained in the narrow tube and strangling the patient. When inserting the feather be sure there is no excess solution on it to be squeezed out in the tube, trickle into the trachea and lungs, causing him to choke, cough and strangle. Again, do not insert it so far as to touch and tickle the patient's throat. This will cause such a spasm of coughing as to possibly strangle him. (If the air is dry this also tickles and irritates, causing a con- stant cough.) The doctor sometimes tickles the throat with the feather purposely in order to make the patient cough and force up mucus or diphtheritic membrane, etc. Care must be taken not to displace the outer tube. Always note the position of the tube, the patient's breathing, color, pulse rate and temperature and whether bleeding or inflammation, etc., occurs around the tube. The head of the patient should be kept slightly lowered to prevent the inhalation of blood or mucus. The patient may be given liquid food through a tube by mouth or nasal feeding may be necessary. Later, when fed by mouth, the tube may be dispensed with and, in some cases, the patient can swallow soft solids with ease after becoming accustomed to the tube. The tube in the trachea does not interfere with swal- lowing for "the absence of cartilaginous rings between the trachea and esophagus avoids the pressure of the trachea upon the esopha- gus which might impede deglutition" (Woolsey). The voice usually is just a whisper with a whistling sound but in some cases without complete obstruction, the voice may be fairly good when a finger is held over the mouth of the tube. When the tube is finally removed the patient must be watched closely until the breathing is normal—some take a long time to resume normal breathing. INDEX Abbreviations, 421 Abdomen, condition of, 48 examination of, position of pa- tient for, 511 Abdominal aspiration, 356, and see Abdominal paracentesis distention, after an operation, 234 operations, nursing care after, 586 paracentesis, 356 anatomical and physiological factors, 356 dangers involved in, 357 methods of procedure, 357 Abscess, 311 stitch, 563 Absorbent cotton, 247 Absorptive power of stomach, to test, 417 Accidents, nursing care in, 599 Accuracy in administration of drugs, 426 Acetone, test for, 461 Acid stains, to remove, 30 Acids, effect of, on teeth, 80 Acidosis, post-operative, 581 Adhesive plaster, 296 strapping, 296 over dressings, 249 Administration of medicines, 419 accuracy in, 426 by hypodermoclysis, 431 by inhalation, 429 by inunction, 438 by intramuscular injection, 431 by mouth, 433 by rectum, 436 channels of, 427 hypodermatically, 431 intravenously, 427 methods of, 424 order book for, 420 responsibility in, 419 subcutaneously, 431 Admission bath, 38 procedure, 41 purpose of, 38 value of, 38 Admission of new patient to hos- pital, 37 Admitting ward, 38 Adults, how differ from infants, 182 Aestivo-autumnal fever, tempera- ture chart in, 146 Affusion, 400 After care of surgical patient, in ward, 230 Age, modifying dosage of drugs, 424 Aged, care of after operation, 237 Air, and see Ventilation, methods of securing control of, 17 movement of in wards, 16 pure, 17 variability of in wards, 16 Air hunger, 179 diabetic, 460 Albumin in urine, test for, 453 Alcohol sponge bath, 403 composition, 403 procedure, 403 Alcoholism differentiated from apo- plexy, 473 Alimentary tract, nursing pro- cedures in diseases of, 405 Alkaline baths, 402 Aluminum, care of, 25 Ammonia, 331, 429 Amoeba, 106 Amyl nitrite, 429 Anemia, 446 cerebral, cause of, 461 how to secure, 70 nursing care in, 446 Anemic paralysis, 627 Anesthetics, effects of, 226 Aneurysm, 446 nursing care in, 446 Ankle, bandage of, 280 strapping, 298 Anoci-association in prevention of shock, 545 Antiphlogistin, 334 conditions in which used, 334 effects of, 334 method of application, 334 Antisepsis, 245 Antiseptic surgery, 244 Antitoxin, diphtheria, 486 Anuria, 120 post-operative, 580 Aortic regurgitation, pulse in, 165 stenosis, pulse in, 166 Apnea, 180 Apoplexy, 472 causes of, 472 differentiated from alcoholism, 473 677 678 INDEX Apoplexy, symptoms, 473 treatment, 474 Applications, 186 Argyrol stains, removal of, 29 Arm, bandage, 270, 275 Arrhythmia, 170 Arteries, compressibility of, 159 condition of wall of, 158 diseases of, nursing care in, 444 pipe-stem, 158 tension of, 159 where pulse may be taken, 155 Arteriosclerosis, 444 nursing care and treatment of, 445 Artificial eyes, care of, 655 to insert, 655 to remove, 655 Artificial pneumothorax, 358 Artificial respiration, 465 Laborde's method, 466 Schafer's method, 465 Sylvester's method, 466 Ascites, conditions causing, 356 Asepsis, 246 Aseptic surgery, 244 Asphyxia, 462 causes, 462 symptoms, 463 treatment, 463 Aspiration, abdominal, 356, and see Abdominal aspiration of chest, 351, and see Aspiration, thoracic of pericardium, 354 anatomical and physiological factors in, 354 dangers involved, 355 procedure, 355 thoracic, 351 dangers in, 352 factors to be remembered in, 352 indications, 351 procedure, 352 Assimilation, conditions which favor, 89 effect of faulty, 88 Associated areas, 322 Astringents, treatment of hemor- rhage by, 605 Auditory canal, see Ear Auscultation towel, 511 Back, care of, 64 strapping, 297 Backache, after an operation, 232 Bacteria, as cause of inflammation, 188 Baking, 200 contraindications, 200 effects, 200 methods, 201 uses, 200 Balsam of Peru stains, removal of, 30 Bandages, application of, principles of, 264 Barton, 284 Canton flannel, 257 circular, 268 cravat, 259 crepe paper, 257 crinoline, 258 demi-gauntlet, 271 double T., 260, 261 elastic, 258 Esmarch's, 258 figure of eight, 269 four-tailed, 259, 261, 262 fundamental, 268 Galen's, 259, 261 gauntlet, 272 gauze, 257 handkerchief, 259 how to make and roll, 263 length of, 263 many-tailed, 259, 261 materials of which made, 257 method of removing, 267 method of securing, 267 mitten, 273 oblique, 268 occipito-frontalis, 284 of ankle, 280 breast, 292 calf of leg, 281 ear, 290, 292 elbow, 274 eye, 288, 289, 290 finger, 270 foot, 278, 279, 280 forearm, 273 groin, 282, 283 hand, 273 head and forehead, 283 head and neck, 284 head, recurrent, 285 leg, 280 lower extremity, 278 neck and shoulder, 276 shoulder, 275 thumb, 272 upper arm, 275 upper extremity, 270 plaster of Paris, 294 removal of, 295 nursing care, 295 to apply, 294 to make, 294 purposes for which used, 257 recurrent, 270 roller, 268 parts of, 264 rubber, 258 Scultetus', 261, 262, 263 single T., 259, 260 INDEX 679 Bandages, six-tailed, 259, 261 spica, 270, 272, 275 spiral reverse, 269, 274 tailed, 259 triangular, 258, 259 types of, 258 unbleached muslin, 257 uses of, 258 Velpeau's, 277 width of, 263 woven, 258 Bandaging, 257, and see Bandages in fractures. 631 principles of, 264 Barton's bandage, 284 Bath, admission, 38, and see Ad- mission bath alcohol sponge, 403 alkaline, 402 bed, 78 best time for, 79 Brandt, 393 contraindications, 394 effects, 393 procedure, 394 cold sponge, 397 continuous, 372 conditions in which used, 373 procedure, 373 results, 373 effervescent, 401 composition, 401 effects, 401 procedure, 401 hot air, 363 conditions in which used, 363 effects, 364 procedure, 364 hot sitz, 328 duration, 329 effects, 328 procedure, 329 hot tub, 371 conditions in which used, 371 contraindications, 371 light, 365 effects, 366 incandescent, 366 procedure, 368 purposes for which used, 367 method of, 80 morning, beneficial effects of, 79 mustard, 402 Nauheim, 401 composition, 401 effects, 401 procedure, 401 number desirable, 79 preparation of, 80 saline, 401 composition, 401 effect, 402 Bath, sedative, 372 conditions in which used, 372 effects, 372 slush, 397 value and purpose of, in disease, 78 vapor, 369 effects, 369 uses, 369 Bathing infants and children, 85 Bed, 33 care of, 35, 36 for patient after operation, 227 hospital, 33 cost of equipment, 34 how to make, 34 with patient in it, 77 Bed-bath, 78 Bedbugs, to prevent, 31 Bedding, care of, 35 Bed linen, 34 Bed pan, method of giving, 103 Bedside table, in dyspnea, 59 Bedsores, 64 danger points, 65 cause, 64 nature of, 64 prevention of, 64, 65, 66, 484 symptoms, 66 treatment, 64, 67 why dangerous, 65 Belongings, personal of patient, re- spect and care for, 43 Benedict's test for sugar in urine, 460 Bier's cups, 335 Bites, poisonous, treatment of, 612 Bladder, anatomy and physiology of, 531 catheterization of, 531, and see Catheterization instillation, 541 irrigation, 539 contraindications, 540 indications, 539 procedure, 540 Blankets, 34 Blister, flying, 339 Blisterers, 338 Blood, chemical composition of, 173 clotting time, test for before operation, 509 coughing of, 608, and see Hem- optysis count, before operation, 508 decreasing volume of, 342 examination of, before operation. 508 in pneumonia, 502 in typhoid fever, 496 groups, 551 in feces, 106 laking of, 332 680 INDEX Blood, letting, 332 pressure, factors in, 160 importance of maintaining nor- mal, 159 normal, 164 relation to pulse, 168 test, before operation, 509 stains, removal of, 28 -sugar test, before operation, 508 test for, in urine, 454 transferring, methods of, 552 transfusion of, 550, and see Trans- fusion Bodily function, interference with, discomfort from, 64 Body, care of after death, 302 condition of, 48 wastes of, elimination of, 102 Bone, injuries to, nursing care in, 621 repair of, 628 Bowels, elimination by, in infectious diseases, 485 Brachio-cervical triangle or sling, 258 Bradford frame, 299 Bradycardia, 169 Brain, anemia of, causes of, 461 how to secure, 70 blood in during sleep, 70 Brandt bath, 393 contraindications, 394 effects, 393 procedure, 394 Breast, amputation of, nursing care after, 586 bandage of, 292 Breath, condition of, 48 Breathing. See Respiration Bronchopneumonia, 497 Buck's extension, 635 Burns, 615 caused by corrosive poisons, 618 classification of, 615 local complications of, 619 of eyes, 654 treatment, 655 symptoms, 615 treatment, 616 local, 616 open, 617 systemic, 618 Calf of leg, bandage, 281 Calomel inhalations, 430 Calories, 136 Camphor, 329 methods of applying, 329 uses of, 329 Cantharides, 338 action of, 338 method of applying, 338 purpose of applying, 338 Cantharides plaster, removal of, 311 Carbohj'drate foods, 86 Carbon dioxid test, before opera- tion, 508 Cardinal symptoms, 134 Castor oil, to disguise taste of, 435 Cataplasm, 207, and see Poultice. Catheterization, 531 anatomical and physiological fac- tors, 531 as aid to diagnosis, 533 conditions in which necessaiy, 532 dangers involved, 534 of male patients, 537 procedure, 538 procedure, 534, 536 to prevent infection of wound, 533 Catheters, 535 care of, 538 glass, 535, 538 gum elastic, 539 Lisle thread, 539 rubber, 535, 538 Caustics, 341, and see Escharotics Cellulitis, 570 symptoms, 571 treatment, 571 Cerebral anemia, causes, 461 how to secure, 70 hemorrhage, 472 differentiated from alcoholism, 473 etiology, 472 symptoms, 473 treatment, 474 Cerebrospinal fluid, examination of, 350 Cerumen in ear, removal of, 661 Chafing, discomfort from, 63 Changing position of patient, 56 Chemical agents as cause of inflam- mation, 188 Chemical cleansing agents, 24 Chemiotaxis, 308 Chest, aspiration of, 351, and see Aspiration, thoracic examination of, position of pa- tient for, 511 strapping, 296 Cheyne-Stokes respiration, 180 Chickenpox, care of skin in, 484 Chilblains, 619 Childhood, diet in, 100 feeding in, 100 Children, bathing of, 85 care of after operation, 238 convulsions in, 471 feeding of, 93 importance of proper feeding, 94 importance of sleep, 74 method of giving enema to, 118 method of holding, for examina- tion of ears, 657, 658 INDEX 681 Children, method of holding, for examination of eyes, 646 for examination of throat, 664 rheumatic fever in, 504 Chloroform as a counterirritant, 331 method of applying, 332 purpose for which used, 331 Chocolate stains, removal of, 29 Choledocholithotomv, nursing care after, 594 Cholelithotomy, nursing care after, 594 Cholecvstectomy, nursing care after, 594 Cholecvstostomy, nursing care after, 594 Cholecvstotomy, nursing care after, 594 Chorea, 504 Circular bandage, 268 Circulatory system, 316 diseases of, nursing care in, 440 Citrate method of transferring blood, 553 Cleanliness, discomfort from lack of, 64 of wards, 21 Cleansing agents, nature and action of, 23 Cleft palate, nursing care after op- eration for, 584 Clinical thermometer, 147 care of, 151 Clonic contractions, 469 Clotting time of blood, test before operations, 509 Clyster, 108 Cocoa stains, removal of, 29 Coffee stains, removal of, 29 Cold, action of, 217 prolonged, 217 application of, 374 alternated with hot applica- tions, 376 contraindications, 376 effects of, 374, 375, 377, 381 in inflammation, 195 purposes of, 374, 381 reflex effect of, 218, 377 results, 319 to check hemorrhage, 604 tonic reaction of, 382 general application of, 388 conditions which discourage re- action, 390 conditions which promote re- action, 390 effects, 388, 389 primary action, 388 local applications, 216, 383 symptoms and signs to be avoided, 218 Cold baths, 388 Cold compress, 384 for chest. 386 for head, 384 Cold packs, 388 contraindications, 392 effects, 388, 390 procedure, 392 Cold sponge bath, 397 Cold wet hand rub, 396 conditions in which used, 396 effects, 396 procedure, 396 Collapse, 462 Colles' fracture, 624, 625 Colloidal gold test, 350, 351 Colon irrigation, 519 anatomical and physiological fac- tors, 519 conditions for which given, 521 factors necessary for best results, 522 procedure, 524 Coma, diabetic, 459 postoperative, 580 Comfort, 50 mental, means of securing, 52 physical, means of securing, 56 Compresses, application of to eyes, 648, 649, 650 Conduction, 19 Congestion, 194, 307, 312 local cutaneous, 203 venous, 318 Conjunctiva, to expose, 651, 652 Conjunctival sac, irrigation of, 651, 652, 653 Constipation, 103 Contentment of patient, 50 Continuous bath, 372, and see Bath, continuous Contractions, clonic, 469 coordinate, 469 tonic, 469 Contusions, 613 symptoms, 614 treatment, 614 Convection, 19 Convulsions, 469 epileptiform, 469 hysteric, 470 in children, 471 treatment, 471 local, 469 points to observe in, 471 tetanic, 470 treatment of, 470 Coordinate contractions, 469 Copper, care of, 25 Corrigan pulse, 166 Corrosive poisons, burns caused by, 618 Cotton, absorbent, 247 682 INDEX Coughing, in infectious diseases, 486 of blood, 608, and see Hemoptysis Counterirritants, 315 action of, 315, 323 meaning of, 315 to relieve inflammation, 315 varieties of, 323 Counterirritation, 199, 327, and see Counterirritants Cradles, suspension, 636 Cream stains, removal of, 29 Crisis, in pneumonia, 501 Critical attitude of nurse, 6 Cupping, dry, 334 conditions and purposes for which used, 335 contraindications, 335 procedure, 335 wet, 345 conditions in which used, 345 method of application, 345 Cutaneous areas reflexly associated with internal parts, 196, 197 Cvclopegics, 645 Cystitis, 539 Dandruff, removal of from ear, 661 Dawson's solution, 556 Death, care of body after, 302 Defecation, importance of regular- ity in, 103 Delayed union, in fractures, 630 Delirium, in infectious diseases, 486 Demi-gauntlet bandage, 271 Democratic spirit of nurse, 7 Departure of patient from hospital, 301 Depletion, 342 Diabetes mellitus, 454 air hunger in, 460 coma in, 459 diet in, 455 dyspnea in, 460 exercise in, 458 fluids in, 457 nursing care and treatment in, 454 rest in, 458 symptoms to be noted in, 459 urine tests in, 460 Diacetic acid, in urine, test for, 461 Dialysis, 557 Diapedesis, 308 Diaper, method of changing, 117 Diet, and see Foods, and Feeding after an operation, 237 in fever and toxemia, 481 varieties of, 91 Diffusion, 556 Digestion, conditions favoring, 89 effect of neglected mouth on, 82 faulty, effect of, 88 Digestive disturbances in infectious diseases, 486 Digitalis, in heart diseases, 444 Diphtheria, antitoxin in, 486 bacillus as cause of, 189 care of ears in, 484, 485 eyes in, 484, 485 nose in, 484, 485 skin in, 483 throat in, 484, 485 complications of, 480 convalescence from, 488 diet in, 482 precautions in, 477 Dirt, removal of, 22 Discharges, care of in infectious dis- eases, 478 condition of, 48 Discomfort, causes of, 51 relief of, 63 Disinfection, in infectious diseases, 478 Dislocations, 622 complications of, 622 symptoms of, 622 treatment of, 622 Double T. bandage, 260, 261 Douches, alternate, 399, 400 cold, 398 effects of, 398 hot, 398 purpose of, 398 Scotch, 399 spinal, 399 Dosage of drugs, factors modifying, 424 Young's rule for, 424 Draping of patient for examinations, 514 Draw sheet, 34 Drugs, and see Medicines factors modifying dosage of, 424 effects of, 424 for producing sleep, 73 Young's rule for dosage of, 424 Dry cupping, 334 conditions and purposes for which used, 335 contraindications, 335 procedure, 335 Dry mouth, washes for, 83 Dust, removal of, 22 Dyspnea, 179 expiratory, 180 inspiratory, 180 Ear, application of dressings to, 657 care of, in infectious diseases, 484 care of secretions from, 478 condition of, 47 examination of, 656, 657 incision of drum, 660 of furuncles on, 660 irrigation of, 658 INDEX 683 Ear, removal of cerumen from, 661 of foreign bodies from, 662 treatments to, 655 Eclampsia, 470 treatment, 471 Effects of drugs, factors modifying, 424 Effervescent baths, 401 composition, 401 effects, 401 procedure, 401 Elastic bandages, 258 Elimination of waste products, 102, 103 Embolism, 60 fat, 627 pulmonary, postoperative, 581 Embolus, 60 Emergencies, medical, 461 nursing care in, 599 Emollient baths, 402, 403 Emotions, effect of on digestion and assimilation, 89 Enamel ware, care of, 25 Enema, 108 alum, 111 anthelmimtic, 112 carminative, 111 cleansing, 108, 109 compound medicated, 111 emollient, 112 evacuating, 108 for general systemic effect, 112 local remedial, 112 measures for retaining, 115 medicated purgative, 110 method of giving, 114 in infant or child, 118 milk and molasses, 111 normal saline, 110 nutritive, 528, and see Rectal feed- ing ingredients of, 529 oil, 109 position of patient, 114 procedure, 113 soapsuds, 109 turpentine, 111 and oil, 111 Energy, 86 Enteric fever, 488, and see Typhoid fever Enteroclysis, 519 anatomical and physiological fac- tors, 519 conditions for which given, 521 factors necessarv for best results, 522 procedure, 524 Epileptiform convulsions, 469 Epispastics, 338 Epistaxis, 606 causes, 606 treatment, 606 Erysipelas, 573 nursing care, 573 symptoms, 573 treatment, 573 Escharotics, 324, 341 action, 342 in common use, 342 method of application, 342 purposes for which applied, 342 Esmarch's bandage, 258 Evening toilet, 73 Ewald's test meal, 414 Examination of patient before op- eration, 507 articles required, 514 positions, 511 preparation, 509 Exophthalmic goiter, nursing care after operation for, 584 Extremities, condition of, 48 position of, 62 Exudates, 352 Eyes, application of compresses to, 648, 649, 650 ointments to, 653 powders to, 654 solutions to, 654 artificial. See Eyes, glass bandage of, 288, 289, 290 burns of, 654, 655 care of, in infectious diseases, 484 condition of, 47 examination of, 645, 646 glass, care of, 655 to insert, 655 to remove, 655 instillation of drops into, 647, 648 irrigation of, 651 removal of foreign bodies from, 654 secretions from, care of, 478 treatments, 645 Eyelids, eversion of, 651 Face, condition of, 48 Fasting stomach test, 416 Fat embolism, 628 Fat foods, 86 Fatigue, effect of on digestion and assimilation, 90 Feces, accumulation of, causes, 108 removal of, 109 results of, 108 blood in, 106 collection of specimen of, 107 mucus in, 105 pus in, 106 what to observe in, 104 Feeding, 86 after operations on stomach, 589 684 INDEX Feeding, of premature infants, 100 rectal. 528, and see Rectal feeding rules for, 90 Fehling's test for sugar in urine, 460 Fever, 142 constant, 144 continuous, 144 course of, 143 crisis, 144 effect of, 88 fastigium, 144 hectic, 147 in infectious diseases, 478 relief of, 485 intermittent, 147, 148 invasion, 143 lysis, 144 onset, 143 recrudescence, 147 recurrence, 147 remittent, 146, 147 stadium, 144 types, 144 Figure of eight bandage, 269 Filtration, 557 Finger, bandage of, 270 Fistula formation, 569 Fleas, 31 to destroy, 32 Flies, to get rid of, 30 Flying blister, 339 Fomentation, 203 procedure, 205 uses, 204 Food, effect of insufficient, 88 effect of on patient, 86 kinds required, 86 Foods, calorie values of, 136 fat, 86 Foot, bandage of, 278, 279, 280 Foreign bodies, removal from ear, 662 from eye, 654 Foot-bath, hot, 211 effects, 211 procedure, 212 purposes, 212 Forearm, bandage of, 273 Four-tailed bandage, 259, 261, 262 Fowler's position, 574, 577 Fractures, 623 after care of, 637 bandaging in, 631 classification of, 624 Colles', 624 complications, 627, 628 comminuted, 624 compound, 623 delayed union in, 630 first aid in, 630 general factors in treatment, 630 greenstick, 624, 625 how to recognize, 626 Fractures, immobilization in, 631, 632 impacted, 624 non-union in, 630 open treatment of, 637 Pott's, 625 reduction of. 632 repair of, 628 responsibility of nurse, 637 simple, 623 splints in, 632 suspension in, 637 symptoms of, 625, 626, 627 traction in, 634 treatment of, 634 varieties, 623 Fresh air, in infectious diseases, 483 Friction, discomfort from, 63 Frost bites, 619 treatment, 619 Fruit stains, removal of, 29 Fumigation, in infectious diseases, 478 Furuncles in aural canal, incision of, 660 Galen's bandage, 259, 261 Gall bladder and ducts, operations on, nursing care after, 594 Gargles, 664 Gas pains after an operation, 234 Gastric lavage, 405 conditions in which used, 405 contraindications, 406 procedure, 407 Gastro-enterostomy nursing care after, 590 Gastrorrhagia, 607, and see Hema- temesis Gastrostomy, nursing care after, 588 Gatch frame, 58 Gauntlet bandage, 272 Gauze, 246 Gavage, 411 conditions in which indicated, 411 procedure, 411 Gavage, nasal, 412 conditions in which indicated, 412 procedure, 412 Glands, condition of, 48 Glass, care of, 25 Glass eyes, care of, 655 to insert, 655 to remove, 655 Goiter, exophthalmic, nursing care after operation for, 584 Gonococcus, as cause of inflamma- tion, 189 Gonorrheal ophthalmia, application of compresses in, 650 irrigation of conjunctival sac. 653 Granulation tissue, formation of, 564 INDEX 685 Grease stains, removal of, 29 Groin, bandage of, 282, 283 Gums, condition of, 48 Habits modifying dosage of drugs, 425 Hair, care of, 41, 83 washing, 84 Hand, bandage of. 273 Hands, preparation of before op- eration, 515 Happiness of patient, 50 Hare lip, nursing care after opera- tion for, 584 Head, recurrent bandage of, 285 Head and forehead, bandage of, 283 Head and neck, bandage of, 284 Headache, after an operation, 232 relief of, in infectious diseases, 485 Healing of wounds, 310, 562 by direct union, 562, 564 by first intention, 310, 562 by primary union, 562 complications of, 568 indolent. 566 redundant, 566 Health, effect on of neglected mouth, 82 needed in nurses, 7 Heart diseases, diet in, 443 drugs in, 444 exercise in, 443 nursing care in, 441 rest in, 441 sleep in, 442 treatment in, 444 urine in, 443 Heart, failing, symptoms of, 441 Heart failure, symptoms of in in- fectious diseases, 486 Heat, 86 action of, 194 application of, 194, 319, 361 dry, 199, 363 in inflammation, 195 moist, 199, 203, 369 elimination of, 137, 138, 319 production of, 136, 319 regulation of, 139 to check hemorrhage, 604 Heat exhaustion, 468 symptoms, 469 treatment, 469 Heat stroke, 467 symptoms, 467 treatment, 468 Heating, means of, 19 types of, 19 Helpless patient, to lift, 61 Hematemesis, 607 causes of, 607 Hematemesis, differentiated from hemoptysis, 608 treatment, 608 Hemoglobin test before operation, 508 Hemolysis, 557 Hemoptysis, 608 causes of, 608 differentiated from hematemesis, 608 treatment, 609 Hemorrhage, 547, 600 external, 548 from nose, 606, and see Epistaxis from stomach, 607, and see Hema- temesis from uterus, 609 internal, 548 local, treatment of, 603 by application of heat and cold, 604 by astringents, 605 by cautery, 605 by ligation, 605 by position, 604 by pressure, 603 by styptics, 605 by suturing, 605 by torsion, 605 by tourniquet, 604 systemic treatment, 605 postpartum, 610 primary, 547 reaction to, 602 secondary, 548 signs of, 548 symptoms of, 548, 602 treatment of, 549, and see Hemor- rhage, local, treatment of varieties of, 600 Hemorrhoids, nursing care after op- eration for, 592 Herniotomy, nursing care after, 588 Hodgen splint, 635 Hospital, admission of new patient to, 37 as a home for sick people, 11 bed, 33 cost of equipment, 34 classification of, 11 functions of, 11 organization of, 12 pests, 30 situation of, 13 structure of, 13 ward, as home for sick people, 14 Hot air apparatus, 201, 202 Hot air bath, 363 conditions in which used, 363 effects produced by, 364 local, 200 procedure, 364 686 INDEX Hot applications alternated with cold applications, 376 Hot baths, 361 effects of, 361, 362 Hot foot bath, 211 effects of, 211 purposes of, 212 procedure, 212 Hot pack, 369 conditions in which used, 370 effects of, 369 procedure, 370 Hot sitz bath, 328 duration of, 329 effects of, 328 procedure, 329 Hot tub bath, 371 conditions in which used, 371 contraindications, 371 Hot water bag, method of applica- tion, 199 uses of, 199 Humidity of ward, 16 Hunger, 88 Hydrophobia, 612 symptoms, 612 treatment, 613 Hygiene, in infectious diseases, 483 Hypertonic solution, 557 Hypnotics, 73 Hypodermatic administration of medicines, 431 dangers of, 431 Hypodermoclysis, 560 administration of medicines by, 431 contraindications, 561 effects of, 560 procedure, 561 uses of, 560 Hypotonic solution, 526, 557 Hysteric convulsions, 470 Ice bag, 216 application of, 219 conditions and purposes for which used, 218 Ice coil, 383 application of, 384 conditions in which used, 383 Ice compress, 216 application of, 219 conditions and purposes for which used, 218 Ichthyol, 332 conditions and purposes for which used, 332 method of application, 333 Idiosyncrasy, modifying dosage of drugs, 425 Immobilization, in fractures, 631, 632 Incandescent light bath, 366 effects of, 366 procedure, 368 purposes for which used, 367 Infancy, pulse in, 182 respiration in, 182 temperature in, 182 Infantile paralysis, care of mouth, throat, nose, eyes and ears in, 485 Infants, bathing of, 85 feeding of, 93, 94 how differ from adults, 182 importance of sleep for, 74 method of giving enema to, 118 stools of, 116 character, 116 habit formation, 117 number, 116 urine of, 132 Infected wounds, 562 complications of, 570 Infectious diseases, complications of, 480, 481 convalescence from, 487 fumigation in, 478 insomnia in, 486 nursing care in, 475 care of secretions and dis- charges in, 478 general principles, 475 to prevent spread, 475 specific treatment, 486 treatment, 481 Inflammation, 186, 307 causes of, 187 definition of, 186, 307 measures to relieve, 313 nature of, 190, 307 pelvic, 213 symptoms of, 189, 308 treatment of, 324 Influenza, complications of, 480 Infusion, intravenous, 555, and see Intravenous infusion Inhalation, administration of drugs by, 429 Inhalations, for nose and throat, 668 Ink stains, to remove, 28 Insolation, 467 Insomnia, in infectious diseases, 486 Instillation, bladder, 541 of drops into eyes, 647, 648 Intestinal parasites, 106 Intestines, elimination of waste products from, 103 operations on, nursing care after, 592 Intramuscular injection of drugs, 431 Intravenous administration of drugs, 427 Intravenous infusion, 555 contraindications, 560 INDEX 687 Intravenous infusion, dangers of, 558 effects, 555 indications, 555, 560 procedure, 559 solutions used, 555 Intubation, 670 Inunction, medication by, 438 Involuntary micturition, 533 Iodides, 435 Iodine, conditions in which used, 330 method of applying, 330 Iodine preparation, for operation, 517 advantages of, 518 Iodine stains, removal of, 29 Irrigation, of bladder, 539 contraindications, 540 indications, 539 procedure, 540 of colon, 519, and see Colon irri- gation of conjunctival sac, 651, 652, 653 of ear, 658 of nose, 669 of throat, 666 of vagina, 238, and see Vaginal irrigation Ischemic paralysis, 627 Isoagglutinins, 552 Isohemolysins, 552 Isolation of patient, diseases in which indicated, 476 rules governing, 476 Isotonic solution, 557 Jaw, operations on, nursing care after, 583 Jejunostomy, nursing care after, 590 Joints, injuries to, nursing care af- ter, 621 Jones' traction splint, 634 Keloid, 568 Kidneys, diseases of, nursing care in, 447, 451 symptoms to be observed in, 448 elimination of waste by, 119 elimination by in infectious dis- eases, 485 functional efficiency of, 449 work of, 447, 448 Kitchen, ward, 25 Knee, strapping, 297 Knowledge needed by nurses, 7 Laborde's method of artificial res- piration, 466 Laking of blood, 558 Laundry, relation of ward to, 2b Lavage, gastric, 405 conditions in which used, 405 Lavage, gastric, contraindications, 406 procedure, 407 Leeches, 342 action of, 342 areas to which applied, 343 conditions in which applied, 343 disadvantages of, 343 method of application, 344 removal of, 344 Leeching, 342, and see Leeches Leg, bandage of, 280, 281 Lice, 41, and see Pediculi Lifting patient, in bed, 56 Light, artificial, 20 electric-arc, 366 in infectious diseases, 483 incandescent, 366 natural, 20 Light baths, 365 effect, 366 incandescent, 366 procedure, 368 purpose for which used, 367 Lighting of ward, 20 Lindeman method of transferring blood, 553 Linen, bed, 34 care and use of, 27 removal of stains from, 27 supply of, 26, 27 Linen room, relation of ward to, 26 Lips, condition of, 48 Locke's solution, 556 Lower extremity, bandage of, 278 Lumbar puncture, 346 anatomical and physiological fac- tors, 346 conditions and purposes for which performed, 348 dangers involved in, 348 procedure, 349 Lungs, relation of to chest wall, 208, 209 Malaria, fever chart in, 147 Many tailed bandage, 259, 261 Marble, care of, 25 Mattress, 33 care of, 36 to turn with patient in bed, 62 Measles, care of mouth, nose, throat, eyes and ears in, 485 care of skin in, 484 complications of, 480 light in, 483 Mechanical agents as causes of in- flammation, 187 cleansing agents, 24 Medical diseases, nursing care and treatment in, 325, 439 Medical ward, elementary nursing in, 185 688 INDEX Medication, to make it acceptable to patient, 435 Medicine chest, 423 Medicine stains, removal of, 29 Medicines, administration of, 419, 431, and see Administration of medicines Meningitis, care of mouth, throat, nose, eyes and ears in, 484 complications of, 480 hygiene in, 483 light in, 483 sensitiveness and pain in, 485 serum in, 487 Meningococcus, as cause of inflam- mation, 189 Mental condition of patient, 47 Menorrhagia, 609 Mercurial ointment, inunction with, 438 Methyl salicylate, method of ap- plication, 333 Metrorrhagia, 609 Mice, to suppress, 32 Micturition, involuntary, 533 Mildew stains, to remove, 30 Milk stains, to remove, 29 Minor surgical procedures, 346 Mitten bandage, 273 Monotony, relief of, 54 Morning toilet, 77 Mosquitoes, to suppress, 31 Moss classification, 551 Moths, to prevent, 32 Mouth, care of, 81, 82 in infectious diseases, 484 condition of, 47 medication by, 433 neglected, effect on health and di- gestion, 82 operations on, nursing care after, 583 to cleanse, 83 washes, 82 Moving of patient from one bed to another, 62 Mucus in feces, 105 Mucus stains, removal of, 29 Mumps, complications of, 480 diet in, 483 Mustard, 214 action of, 214 bath, composition of, 402 effects produced by, 214 leaf, 216 paper, 216 paste, conditions and purposes for which used, 215 method of preparing and ap- plying, 215 poultice, 211 Mydriatics, 647 Myringotomy, 660 Narcotics, 73 Nauheim bath, 401 composition, 401 effects, 401 procedure, 401 Nausea, after an operation, 233 Neck and shoulder, bandage of, 276 Neosalvarsan, 427 Nephrectomy, nursing care after, 595 Nephrolithotomy, nursing care after, 595 Nephrotomy, nursing care after, 595 Nephritic test diet, 450 Nephritis, acute, 447 nursing care and treatment in, 447, 451 urine, in 448 chronic, 447 nursing care and treatment in, 447, 451 urine in, 449 Nervous system, 319 Nickel, care of, 25 Night, preparation of patient for, 73 Nitrites, in heart disease, 444 Noise, effect of, 55 Non-union of fractures, 630 Normal salt solution, 555 Nose, care of in infectious diseases, 484 condition of, 47 examination of, 663 inhalations in treatment of, 668 irrigation of, 669 secretions from, care of, 478 sprays, in treatment of, 665 treatment for, 663 Nose-bleed, 606, and see Epistaxis Nurse, ideals of, 5 influence of, 3 relation of to patient, 5 reliability of, 6 responsibility of, 5 spirit of, 5 Nursing, field of, 3 object of, 3 qualities needed in, 7 training needed in, 7 what it includes, 4 Nutritive enema, 528, and see Rec- tal feeding Obedience, of nurse, 6 Oblique bandage, 268 Observation, importance of, 134 of sick, 45 Occipito-frontalis bandage, 284 Occupation modifying dosage of drugs, 425 Oil stains, removal of, 29 Ointments, application of to eyes 651 INDEX 689 Oliguria, 120 Open air treatment of pneumonia, 499 Operations, complications following, 543 discomforts following, 232 effects of, 226 emergency preparation for, 518 preparation of field, 515, 516, 517, 518 preparation of patient for, 507, 514 Ophthalmia, gonorrheal, application of compresses in, 650 irrigation of conjunctival sac in, 653 Ophthalmia neonatorum, applica- tion of compresses in, 650 irrigation of conjunctival sac in, 653 Order book for medicines, 420 Orthopnea, 58, 179 Osmosis, 557 Otitis media, symptoms to be watched for in, 663 Oxygen, 429 Pain, referred, 320 reflex, 321 relief of in infectious diseases, 485 Pain sense, 318 and sensory centers, 320 Paquelin thermocautery, 327 Paracentesis, abdominal, 356 anatomical and physiological factors, 356 dangers involved in, 357 procedure, 357 Paralysis, anemic, 627 infantile, care of mouth, throat, nose, eyes and ears in, 485 ischemic, 627 Parasites, intestinal, 106 Patient, admission to hospital, 37 bringing back to ward after opera- tion, 228 departure from hospital, 301 examination before operation, 221 personal belongings of, care for, 43 preparation for night, 73 for operation, 221 reception of in hospital, 37 types of, 37 welcome of in hospital, 37 Pediculi, 42 detection of, 42 prevention of, 42 removal of, 42 varieties of, 42 Pediculus capitis, 41 corporis, 41 pubis, 41 Pelvic inflammation, reflex and flexion effects of, 213 Pelvic organs, position of patient for examination of, 512 Pericardium, aspiration of, 354, and see Aspiration of pericard- ium Perineorrhaphy, nursing care after, 598 Peritonitis, 574 causes of, 576 diet in, 578 symptoms of, 576 treatment of, 576 Perspiration, 316 decreased by, 317 functions of, 317 increased by, 316 stains, removal of, 29 Phagocytosis, 308 Phenolsulphonephthalein test, 449 Phlebitis, 63 Phlebotomy, 359 conditions in which used, 359 procedure, 359 Physical agents, as cause of inflam- mation, 187 Picric acid stains, removal of, 29 Pillow slips, 34 Pillows, 33 care of, 36 Pinworm, 106 Plaster, adhesive, 296 Plaster of Paris bandages, 294 nursing care in cases requiring, 295 removal of, 295 to apply, 294 to make, 294 Pleura, relation of to chest wall, 208, 209 Plumbing, 21 Pneumonia, 497 antipneumoccic serum in, 500 complications, 499 convalescence in, 501 crisis in, 501 diet in, 498 drugs in, 500 elimination in, 498 examination of blood in, 502 of urine in, 502 in children, 502 nursing care, 502 nursing care and treatment in, 497, 498, 502 post-operative, 578 preventive measures, 579 symptoms, 579 treatment, 579 prophylaxis. 501 pulse in, 145 respiration in, 145 690 INDEX Pneumonia, temperature in, 145 tests used in, 502 Pneumothorax, 358 artificial, 358 Poisons, corrosive, burns caused by, 618 Poliomyelitis, complications of, 480 sensitiveness and pain in, 485 Porcelain, care of, 25 Position, in treatments, 315 to relieve inflammation, 314 dorsal elevated, 512 dorsal lithotomy, 512 dorsal recumbent, 512 erect, 514 genupectoral, 514 horizontal recumbent, 512 knee-chest, 514 left lateral prone, 514 Sims', 514 standing, 514 Trendelenberg, 514 Post-operative acidosis, 581 coma, 580 complications, 570, 580 nursing care in, 570 prevention of, 570 treatment, 570 pneumonia, 578 preventive measures, 579 symptoms, 579 treatment, 579 pulmonary embolism, 581 thrompophlebitis, 581 symptoms, 582 treatment, 582 Postpartum hemorrhage, 610 Pott's fracture, 625, 626 Poultice, 207 effects of, 208 mustard, 211 procedure, 208 uses, 208 Powders, application of to eyes, 654 Practical nursing, supervision of, 8, 9 "Precautions," diseases in which pa- tients are placed on, 475 Premature babies, feeding of, 100 Pressure, to relieve in inflammation, 314, 315 Pressure sores, 64, and see Bedsores Privacy, 55 Proctoclysis, 525 procedure, 526 purposes for which employed, 525 Professional spirit of, 6 Prostatectomy, nursing care after, 595 Protein food, 86 metabolism, waste products of in urine, 129 Pulmonary, embolism, post-opera- tive, 581 Pulse. 134, 152 bigeminal, 170 capillary, 160 dicrotic, 162, 163 high tension, 161 how to take, 156, 184 hypertension, 161 hypotension, 162, 163 importance of careful observation of, 134, 153 in infants, 182 how to take, 184 intermittent, 170 low tension, 162, 163 normal, 156 rate of, 166 relation to blood pressure, 168 rhythm of, 169, 170 trigeminal, 170 venous, 160 volume of, 165 what to note in taking, 156 where it can be taken, 154, 155 Pulse tracing, dicrotic, 161, 163 hard, high tension, 161 high tension, 161 hyperdicrotic, 161 intermittent, 170 irregular, 16° 170 in aortic regurgitation, 165 in aortic stenosis, 166 in old man, 159 low tension, 161, 163 normal, 157, 161 soft, 161, 163 Pulse wave, 152 Corrigan's, 166 shape of, 165 size of, 165 water hammer, 166 Pus, 193 in feces, 106 Pyemia, 571 nursing care in, 572 symptoms, 572 treatment, 572 Pylorectomy, nursing care after, 590 Pyrexia in infectious diseases, 478 relief of, 485 Rabies, 612 symptoms, 612 treatment, 613 Radiation, 19 Rats, to suppress, 32 Reception ward, 38 Rectal feeding, 528 conditions in which used, 529 purpose of, 528 retention and absorption in, 530 INDEX 691 Rectal infusion, 525, and see Proc- toclysis suppositories, 436 tips, care of, 116 tubes, care of, 115 Rectum, administration of medi- cines by, 436 nursing care after operations on, 594 Recurrent bandage, 270 Referred pains. 320 Reflex pains, 321 Refrigerator, care of, 26 Refuse, care of, 26 Relaxation, 50 Renal complications, post-opera- tive, 580 Reproductive organs, nursing care after operations on, 597 Resolution, 193, 310 Respiration, 134, 171 cause of, 172 character of, 178 Cheyne-Stokes, 180 conditions causing decrease in rate of, 177 variations in rate and depth of, 175 deep, 178 external, 172 importance of observation of, 134 internal, 172 in infants, 182 how to take, 184 method of taking, 174, 184 normal, 173 pulmonary, 172 purpose of, 171 rate of, 174 regulation of, 172 shallow, 178 tissue, 172 vital importance of, 171 what to observe in, 174 Respiratory center, 172 Responsibility of student, 14 Rest, 50, 69 in fever and toxemia of infectious diseases, 481 to relieve inflammation, 313 treatment by, 314 Restlessness, after an operation, 235 in infectious diseases, 486 Retention of urine, 120, 532 after operation, 236 relief of, 120 symptoms of, 120 Rheumatic fever, 503 complications, 503 diet in, 503 drugs in, 503 in children, 504 nursing care in, 503 Rheumatic fever, relief of pain in, 503 Riegel's test meal, 416 Ringer's solution, 556 Ringer-Locke solution, 556 Roaches, 30 to get rid of, 31 Roller bandage, 268 Room, preparation for patient after operation, 226 Round worm, 106 Rubber bandages, gloves, to cleanse and sterilize, 253 sheet, 34 care of, 36 to cleanse and sterilize, 253 Rubbing, discomfort from, 63 Rubefacients, 323 chemical, 329 mechanical, 334 physical, 327 Rust stains, removal of, 29 Saline baths, 401 composition of, 401 effects of, 401 Saline solutions, see Salt solutions Salol test of motility of stomach, 416 Salt solutions, hypertonic, 557 hypotonic, 526, 557 isotonic, 557 normal, 555 Salts, need of, 87 Salvarsan, 427 Sandbags, 300 Sapremia, 571 nursing care in, 572 symptoms, 572 treatment, 572 Scalds, 615 Scar formation, 568 Scarlet fever, care of skin in, 483, 484 complications of, 480 convalescence from, 488 diet in, 482 hygiene in, 483 Schafer's method of artificial res- piration, 465 Scientific spirit of nurse, 6 Scultetus' bandage, 261, 262, 263 Sebaceous glands, 317 Secretions, care of in infectious dis- eases, 478 Sedative baths, 372 conditions in which used, 372 effects of, 372 Seepage, 525, and see Proctoclysis Sensations, effect of on digestion and assimilation, 89 Sensitiveness, relief of in infectious diseases, 485 692 INDEX Sensory centers and pain sense, 320 Sepsis, acute general, 571, and see Septicemia Septic intoxication, 571, and see Septicemia Septicemia, 571 nursing care in, 572 symptoms of, 572 treatment of, 572 Sequestrum, 569 Sewage disposal, 21 Sex, modifying dosage of drugs, 425 Sheet, 34 Shock, 543, 599 anoci-association in prevention of 545 causes of, 544 explanation of, 543 prevention of, 545 post-operative, 543 symptoms of, 544 treatment of, 545 Shoulder, bandage of, 275, 276 Sick, observation of, 45 Sickroom, precautions in in infec- tious diseases, 477 Signs, physical, 46 Silver, care of, 25 Silver nitrate stains, removal of, 29 Sims' position, 514 Sinapism, 214, and see Mustard nls stpt* Single T. bandage, 259, 260 Sinus formation, 569 Sitting up, in bed, 57 in chair, 59 Six-tailed bandage, 259, 261 Skin, 316 care of in infectious diseases, 483 condition of, 48 functions of, 40 nerves of, 317 Sleep, 69 ' blood in brain during, 70 causes of, 69 drugs for producing, 73 importance of, 69 for infants and children, 74 produced by drugs, 73 by waste products, 72 by withdrawal of stimuli, 72 Sleep in infancy and childhood, 74 amount required, 75 character of, 75 conditions necessary for, 75 importance of, 74 Sleeplessness, after an operation, 235 Slings, 259 Slough,193, 310 Slush bath, 397 Smallpox, care of skin, mouth, nose, throat, eyes and ears in, 484 Smallpox, precautions in, 477 Soap, 24 Soiled dressings, disposal of, 254 Solution, application of to eyes, 654 Dawson's, 556 hypertonic, 557 hypotonic, 526, 557 isotonic, 557 Locke's, 556 normal, 555 Ringer's, 556 Ringer-Locke's, 556 salt, 555 Soporifics, 73 Sordes, washes for, 83 Sore throat in infectious diseases, 486 Spartan spirit of nurse, 6 Spasms, 469 Sphygmographic tracings, see Pulse tracings Sphygmomanometer, 164 Spica bandage, 270, 272, 275 Spiral reverse bandage, 269, 274 Spitting of blood, 608, and see Hemoptysis Splints, for fractures, 632 Hogden's, 635 Thomas' traction, 633, 635 Sponge bath, 397, 403 Sprains, 621 symptoms, 621 treatment, 621 Spread (bed-), 34 Spray, 397 in treatment of nose and throat, 665 Stains, removal of, 27, 28 Staphylococci, as cause of inflam- mation, 189 Starvation, 88 Sterilization, of enamelware, 251, 252 of glassware, 251, 252 of instruments, 250, 252 of rubber goods, 252, 253 of syringes, 251, 252 Stings, poisonous, treatment of, 612 Stitch abscess, 563 Stomach, absorptive power of, 417 bleeding from, 607, and see Hem- atemesis contents, expression of, 413 conditions in which indicated, 413 procedure, 417 summary of results, 418 test meals, 414 motor activity of, 413 nursing care after operations on, 588 secretory activity of, 413 Stomach tube, care of, 411 INDEX 693 Stools, and see Feces examination of in typhoid fever, 497 Stramonium inhalations, 431 Strangeness, feeling of, 55 Strapping, adhesive, 296 of ankle, 298 of back, 297 of chest, 296 of knee, 297 Streptococci, as cause of inflamma- tion, 188 Stupe, 203, and see Fomentation Styptics, treatment of hemorrhage by, 605 Subcutaneous administration of medicines, 431 Sugar (blood-), test for before operation, 508 Sugar in urine, test for, 460 Sulphur bath, 403 procedure, 403 Sunstroke, 467 Suppositories, 436 method of procedure, 437 rectal, 436 urethral, 437, 438 vaginal, 437 varieties of, 436 Suppression of urine, post-operative, 580 Suppuration, 193, 311 prevention of, 562 Surgical diseases, care and treat- ment in, 505 Surgical dressings, 243 assisting with, 254 adhesive plaster over, 249 cleaning up after, 252 completing, 249 making of, 246 making patient comfortable after, 249 preparation of patient for, 248 purpose of, 246 soiled, disposal of, 254 Surgical nursing, elementary, 221 Susceptibility, modifying dosage of drugs, 425 Suspension, in fractures, 637 Suspension cradles, 636 Sylvester's method of artificial res- piration, 465 Symptoms, 46 cardinal, 134 objective, 46 subjective, 46 to be noted in daily care of pa- tient, 47 Syncope, 461 causes, 461 symptoms, 462 treatment, 462 Tachycardia, 168 Tapeworms, 106 Tea stains, removal of, 29 Teeth, care of, 81 condition of, 48 effect of acids on, 80 Temperament, modifying dosage of drugs, 425 Temperature, 134, and see Fever, and Heating above normal, 142 and pulse, relation, 168 below normal, 143 body, 136, 140 departures from normal, 141 curve, 143 discomfort from extremes of, 64 importance of observing, 134 in infants, 182 how to take, 184 of ward, 15 taking, 149, 184 by mouth, 149 in axilla, 150 in groin, 150 in rectum, 150 Temperature sense, 317, 318 Test, absorptive of stomach, 417 for albumin in urine, 453 for acetone in urine, 461 for blood clotting time before operation, 509 for blood in urine, 454 for blood pressure before opera- tion, 509 for blood sugar before operation, 508 carbon dioxid, before operation, 508 colloidal gold, 350, 351 for diacetic acid in urine, 461 diazo, in typhoid fever, 497 fasting stomach, 416 for grouping, before transfusion, 551 for hemoglobin, before operation, 508 phenolsulphonephthalein, 449 salol, of motility of stomach, 416 for sugar in urine, 460 vital staining, 552 Widal, in typhoid fever, 496 Test meals, 414 Ewald's, 414 Riegel's, 416 Tetanic convulsions, 470 Tetanus, 574 Thermic impressions, 317 Thermo-cautery, 327 procedure, 328 uses, 328 Thermometer, clinical, 147 care of, 151 694 INDEX Thirst, after an operation, 232 in infectious diseases, 486 Thomas traction splint, 633, 635 Thoracic aspiration, 351, and see Aspiration, thoracic Thread worm, 106 Throat, care of in infectious dis- eases, 484 condition of, 48 examination of, 663, 664 gargles for, 666 in infectious diseases, 486 inhalations for, 668 irrigation of, 666 secretions from, care of, 478 sprays for, 665 treatment of, 663 Thrombo-phlebitis, post-operative, 581 symptoms, 582 treatment, 582 Thrombus, 60 Thumb, bandage of, 272 Toleration, modifying dosage of drugs, 425 Tongue, coated, washes for, 83 condition of, 47 Tonic contractions, 469 Tourniquet, 604 Toxemia, 571 in infectious diseases, 479 care and prevention of, 481 nursing care in, 572 symptoms, 572 treatment, 572 Tracheotomy, 672, 673 after care, 675 dangers following, 675 indications for, 672 high, 673 low, 673 Traction, in fractures, 634 splint, Thomas', 633, 635 Trained faculties needed in nurses, 7 Training, conditions and facilities necessary for, 10 Transferring blood, methods of, 552 citrate method, 553 Lindeman's method, 553 Unger's method, 552 Transfusion, 550 dangers of, 551 difficulties of, 551 effects, 550 indications, 550 methods, 552 citrate method, 553 Lindeman's method, 553 Unger's method, 552 procedure, 554 test for grouping before, 551 Transudates, 351 Trendelenberg position, 514 Triangular bandage, 258, 259 Trustworthiness of nurses, 6 Tubercle bacillus as cause for in- flammation, 189 Tuberculosis, fever chart in, 148 Turning of patient, 57 Turpentine, 332 conditions in which used, 332 Typhoid bacillus as cause of inflam- mation, 189 Typhoid fever, 488 abdominal pain, tenderness and distention in, 491 alcohol in, 493 backache in, 491 bedsores in, 490 blood tests in, 496, 497 care of mouth and nose in, 490 complications to be guarded against, 494 convalescence, care during, in children, 496 diazo test in, 497 diet in, 492 elimination in, 493 headache in, 491 hemorrhage complicating, 495 insomnia in, 491 nursing care and treatment in, 488 perforation complicating, 495 precautions in, 477 rest in, 489 retention of urine in, 491 stools, examination of, 497 temperature chart in, 146 tests used in, 496 thirst in, 491 to prevent spreading, 495 toxemia, relief of, 494 urine, examination of, in, 497 Widal test in, 496 Ulcer formation, 568 Unger method of transferring blood, 552 Upper extremity, bandage of, 270 Uremia, 453 nursing care and treatment of, 447, 451 Uremic coma, post-operative, 580 Urethra, 531 Urethral suppositories, 437, 438 Urinalysis, 453, 460, and see Tests, and Urine Urinary tract, nursing care after operations on, 595 Urine, 119 abnormal constituents in, 132 acetone in, 461 albumin in, 125 amount, 119, 132 blood in, 454 INDEX 695 Urine, chlorides in, 130 collection of specimen, 124, 132 collection of sterile specimen, 132 color of, 123 diacetic acid in, 461 diazo test, 497 epithelial cells in, 125 examination of, 448 before operation, 507 in diabetes mellitus, 460 in nephritis, 448, 449 in typhoid fever, 497 glucose in, 126 in pneumonia, 502 leucocytes in, 125 odor of, 124 method of sending specimen to laboratory, 127 nitrogen in, 129 of infant, 132 phenolsulphonephthalein test, 449 post-operative specimen, 126 pre-operative specimen, 126 reaction of, 124 retention of, 120, 532 post-operative, 236 retention of salts in, 131 routine specimen of, 124 specific gravity of, 124 stains, to remove, 30 sugar in, 126, 460 suppression of, 120, 122 transparency of, 123 twenty-four hours' specimen, 127 errors to be avoided in col- lecting, 127 urea in, 130 waste products in, 129 Uterus, hemorrhage from, 609 causes of, 609 treatment, 610 Vagina, 240 Vaginal irrigation, 238 after care, 242 contraindications, 238 precautions in infectious condi- tions, 243 procedure, 241 purposes for which employed, 239 sterile, 243 Vaginal suppositories, 437 Vagus, sensory fibers from lungs and larynx, 173 Vapor baths, 369 effects, 369 uses, 369 Vaseline stains, removal of, 29 Velpeau bandage, 277 Venesection, 359, and see Phlebot- omy Venous congestion, 318 Ventilation, and see Air of ward, 15 Vesicants, 324, 338 Visitors, effect of, 55 Vital knot, 172 Vital staining test, 552 Vital symptoms, 182 Vomiting, after an operation, 233 Ward, admitting, 38 daily care of, 14 housekeeping, 14 hygiene, 14 kitchen, 25 relation to laundry, 26 to linen room, 26 return of patient to after opera- tion, 225 temperature of, 15 Wastes of body, elimination of, 102 Water, as cleansing agent, 23 need of, 87 supply, 21 Wax, removal from ear, 659 Wet cupping, 345 conditions in which used, 345 method of application, 345 Wet dressing, advantages and dis- advantages of, 517 Whooping cough, complications of, 480 diet in, 483 hygiene in, 483 precautions in, 477 Widal test in typhoid fever, 496 Willingnesss of nurse, 6 Wounds, accidental, 610 dangerous effects of, 610 contused, 610 healing of, 310, 562, and see Heal- ing of wounds incised, 610 infected, 562 complications of, 570 lacerated, 610 poisoned, 610 punctured, 610 stab, 610 treatment, 611 Young's rule for dosage of drugs, 424 WY 100 H287t 1922 54130040R NLM 05EA5020 fl NATIONAL LIBRARY OF MEDICINE NLM052850208