Part 8

The prevention and treatment of bed-sores have been and are frequently discussed in medical books and journals. But as it is a subject that often taxes the nurse’s ingenuity to the extreme, it can not be dwelt upon too frequently. Many preventive measures are familiar to us, as the soap and water bath for cleanliness, followed by rubbing with alcohol and dusting with boric-acid powder, or boric-acid powder and bismuth subnitrate in equal parts for dryness. _The relief of pressure is most important._ Make use of air-cushions, cotton-pads, pillows, water-bed and _frequent change of position_ where that is possible. In addition to these, there are a few measures not generally used which after a thorough test have proved satisfactory. One is a simple inexpensive contrivance used to relieve pressure of heel, elbow, and ear. It is a pig’s bladder filled two-thirds full of either warm or cold water, as the case requires, tied securely, and placed under a cotton ring. The weight of the head or elbow rests on the ring and the tender point rests on the soft fluctuating mass. If the skin is inactive, as in paralysis, or there is frequent or constant moisture from perspiration or involuntary evacuations of urine or feces, the alcohol and boric acid, etc., are of very little value. They do not prevent the absorption of the moisture by the skin and its subsequent softness or excoriation, which is commonly followed by infection. In such cases the back should be washed with soap and water every six or eight hours, or after every involuntary evacuation, and thoroughly rubbed with a small amount of oil-substance, as camphorated oil or a mixture like the following:

Mutton tallow, ℥j; Olive oil, f℥j; Carbolic acid, 95 per cent., ♏︎j.

Render out mutton tallow on the back part of the stove; do not brown it. Strain through a piece of muslin; add the olive oil and carbolic acid; set dish into cold water and beat its contents until set. This will make an ointment the consistence of vaseline, and it will keep indefinitely. If the skin needs a great deal of stimulation, camphorated oil or, better still, castor oil may be substituted for the olive oil in the above recipe.

When the skin becomes excoriated the part should be cleansed as mentioned before, not with soap and water, but with boric-acid solution, normal salt solution, or sterile water; then gently painted with oxide of zinc ointment made into liquid form by the addition of olive oil, castor oil, and balsam of Peru in equal parts, or castor oil alone, and covered with a clean cloth fastened on with a binder. Gentle massage may be used around the excoriated surface with excellent results.

_The_ =treatment of bed-sores= _is usually directed by the physician_; but if it is left to the nurse, she will find the following method helpful. If there is necrotic tissue or suppuration present, she may irrigate the cavity once daily with peroxid of hydrogen, one glass syringeful, followed by normal salt solution, boric-acid solution, or sterile water. Then apply a hot boric-acid dressing, one inch thick, every four hours until wound is clean. If the stimulation of the tissues is needed, fill the cavity with a sterile dressing saturated with balsam of Peru and castor oil, equal parts bovinine, castor oil, or camphorated oil alone. When the depression is filled with granulation tissue, it can be treated as an excoriation.

THE MOUTH.

The subject of the care of the mouth in fever nursing is equally as important as that of prevention of bed-sores. An unclean mouth is not only very unpleasant and often painful to the patient, but is a source of infection. The accumulation of food and mucus is a fertile field for the lodgement of bacteria. If this infected material is allowed to remain, it can easily spread to the middle ear and the mastoid cells, and cause abscesses or be carried by the food to the already overburdened alimentary tract to add to its infection. When the accumulation of sordes is profuse and persistent the patient’s mouth ought to be cleansed after every feeding. This may be done by wrapping a two-inch square piece of linen or gauze, saturated with the mouth-wash, around the little finger and wiping every portion of the cavity—not far enough on back of the tongue to provoke nausea. If it is necessary to clean the throat, a small swab may be employed. For thorough cleaning of the mouth several sponges are necessary. These may be received in a piece of paper and at once burned. While cleaning the mouth of a delirious patient the nurse for her own protection must place some hard substance between the patient’s teeth. A rubber cork is the best, but if that is not available, a fork-handle may be used. Its prongs must be carefully wrapped to avoid an accident. If the cork is used, the nurse must hold it in place to prevent its falling down the patient’s throat. There are numerous preparations used for cleaning the mouth, as:

1. Listerin, f℥j; Water, f℥ij.

_Dobell’s Solution._ 2. Borax, ʒss; Sodium bicarbonate, ʒiv; Listerin, fʒj; Carbolic acid, 95 per cent., ♏︎viij; Warm water, f℥x.

3. Boric-acid solution, f℥j; Alcohol, fʒss; Glycerin, fʒj; Tincture of myrrh, f♏︎j.

4. Glycerin, Water, of each, f℥ss.

The following three formulæ have been found excellent for special cases:

_For Mucus-coated Mouth._

1. Sodium bicarbonate, gr. x; Glycerin, fʒij; Water, enough to make, f℥ij.

If the coating be of long standing, thick and dry, this solution may be applied with an applicator every five or ten minutes for one hour, and then the cleansing may be done with sponges. In these cases it is necessary to use a toothpick to gently loosen the sordes between the teeth.

For dry or fissured lips and tongue, and for anointing the baby’s nose, the following will be found useful:

2. Lanolin, Vaselin, of each, ℥j; Oil of gaultheria, ♏︎xxx. Apply small quantity several times daily.

In rare cases there is a persistent bleeding from the gums. The application, several times daily, of the following solution is effectual:

3. Tincture of myrrh, ♏︎xxx; Water, f℥j.

_Mouth-Wash._

A solution of potassium chlorate and cinnamon water.

DISINFECTION OF ROOMS.

Seal all crevices about doors and windows. Keep the room closed for twenty-four hours to allow dust to settle. At the end of this time vaporize in a lamp from fifty to sixty paraform tablets to each 1000 cubic feet of space or vaporize 1 pound of formaldehyd solution in a _special apparatus_ designed for the purpose. If no special apparatus is obtainable, sprinkle sheets with the following solution, using a gallon of the mixture for a medium-sized room, and fill the room with steam:

Formaldehyd sol., 4 parts; Glycerin, 1 part; Water, 2 parts.

The steam and glycerin prevent to some extent the conversion of the formaldehyd gas into paraform, which in itself is useless.

Another and more modern method is to pour 12 ounces of formaldehyd into a vessel and then add 4 ounces of crystals of potassium permanganate. Place the vessel in the room and leave the room closed for from four to six hours. To get rid of the fumes quickly after the disinfection is completed, sprinkle 4 ounces of ammonia on a sheet and leave the sheet in the room until the ammonia is evaporated.

_Sulphate of copper_ solution is a very cheap disinfectant, and may be used to advantage in typhoid fever.

After this treatment again keep the room closed for four or five hours. Then wipe floor, walls, and woodwork with corrosive sublimate solution (1: 2000) or carbolic acid solution (3 per cent.).

DISINFECTION IN PRIVATE NURSING.

In a private home (M. D. P., _American Journal of Nursing_) if contagion has taken the family by surprise and a room has not been especially prepared, leave in the room all the furniture and fittings in order that everything may be disinfected finally.

During the progress of the disease no blankets, coverings, etc., must ever be shaken from the windows. They can only be aired within the room, or rooms, occupied by the patient. Moist sheets hung outside the door leading to the rest of the house prevent the passage of dust from the sick-room. It is sufficient to keep them sprinkled with plain water, as the important thing is the moisture. However, a solution of carbolic acid may be used. They should be kept wet by some one on the clean side of the house. Soiled linen from the sick-room should be placed in a wash-boiler or metal can full of water, never taken to the laundry in a dry condition. Here also a weak solution of carbolic acid maybe used, or a very weak solution of soda. However, plain water will be sufficient. They should be boiled for at least half an hour. Patients’ dishes and silver should be kept in the room, and before returning to the house should be boiled.

All cleaning within the patient’s room during illness should be done with moist cloths, which should be put into paper bags and burnt.

Upon leaving the room the patient should receive an unusually thorough bath, hair and all, with tincture of green soap, a dilute alcohol rub, and finally a sponge-bath of bichlorid of mercury, 1: 2000 to 1: 4000, according to age.

The mode of disinfecting rooms is, generally, to use formaldehyd.

Before setting free formaldehyd in any form the nurse should put on rubber gloves, glasses, and a thick mouth and nose protector, as the fumes are very irritating. After leaving the room she should seal up the door and leave all over night, and then thoroughly air and house-clean on the morrow. Mattresses and pillows had better be steam-sterilized if there is any sterilizing plant in the town, or, in the country, made over and sunned thoroughly.

SURGICAL SUPPLIES.

TO STERILIZE INSTRUMENTS.

1. All instruments should be boiled for at least fifteen minutes in a 1 per cent soda solution. _Wrap the blades of knives and scissors in cotton_, put them in a separate towel, and in one corner stick the needles before folding it. Some surgeons prefer to have the latter simply washed and placed in absolute carbolic acid and then in alcohol for a few minutes. Water _must boil_ before instruments are put in and the boiler must be kept closely covered.

2. In a German medical journal, published at Leipsic, Gerson corroborates his former assertions as to the efficacy of disinfection of instruments with tincture of soap, citing extensive bacteriologic tests in evidence. He wraps the blades in Brun’s cotton, impregnated with tincture of soap. The cotton protects them from the air and the tincture is an efficient disinfectant. The instruments are then ready for use at any moment. After using them he rubs them clean with cotton moistened with the same tincture, then wraps them in a fresh piece and lays them aside. No boiling or steaming is required, and the instruments are not harmed by the process. He recommends this method especially for military and other practice where steam disinfecting appliances are not available. He has found that instruments infected with pus, etc., and not even wiped off after having been used, proved perfectly sterile after a few days in the wet cotton wrapper. No colonies developed when they were rubbed on agar plates or soaked in bouillon.

_To Arrange Instruments for the Convenience of the Operator._—Instruments for immediate use are laid in trays on a small movable table on the operator’s right hand. Instruments that may not be needed are kept in another tray. A separate tray is used for suturing material, needles, a pair of sharp-pointed scissors, and long forceps. Before placing instruments in the tray, dry with sterile towels.

TO CLEAN INSTRUMENTS.

_First of all_, the knives, scissors, and needles should be laid carefully aside and cleaned at once. Scrub all instruments in cold water to remove blood and pus, then in hot water with plenty of soap. Rinse thoroughly in hot water, then place in boiling water, take them out singly and dry; _do not drain_. Following pus cases all instruments must be boiled for at least fifteen minutes in 1 per cent. soda solution.

TO STERILIZE GLOVES.

Examine carefully to see that they are in perfect condition. Select a pair, then wrap each one in a separate piece of gauze, fasten together, and boil at least 15 minutes in salt solution.

TO DRY STERILE GLOVES.

Cover a table with a sterile sheet. Prepare hands and person as for an operation, and draw on a pair of sterile gloves. Then dry gloves with sterile towel, and powder them inside with sterile powdered talcum.

TO CLEAN GLOVES.

Soak in cold water, then wash with green soap and hot water. Rinse and dry. If used in pus cases, boil 15 minutes before laying away.

TO STERILIZE SILK-WORM GUT OR SILK THREAD.

Boil in sterile water 20 minutes and preserve in alcohol, 95 per cent., or first sterilize in steam sterilizer for 20 minutes, then boil in sterile water for 20 minutes and preserve in alcohol, 95 per cent.

TO STERILIZE HORSE-HAIR.

1. Wash thoroughly in green soap and water. Rinse several times. Soak in ether 24 hours. Boil in sterile water 20 minutes. Preserve in alcohol, 95 per cent.

2. Soak in bichlorid solution 1: 1000 for 6 hours. Then boil 3 minutes in sterile water. Place in alcohol, 50 per cent.

TO STERILIZE CATGUT (FORMALDEHYD METHOD).

Immerse in formaldehyd sol., 5 per cent., for 24 hours. Wash by soaking in sterile water for 24 hours, which must be changed every hour. Then boil in sterile water and basins about 10 minutes, according to size of the catgut. Lift out carefully, and place on a sterile towel until all moisture is absorbed. Prepare table, hands, and person as for an operation. Cut in required lengths, from 14 to 25 inches. Coil smoothly, and preserve in glass jars (which have been previously boiled for 20 minutes) containing the following solution:

Corrosive sublimate, 1 part; Boiled glycerin, 200 parts; Alcohol, 95 per cent., 1000 “ .

CHROMIC CATGUT.

1. Soak in ether 1 to 2 weeks, according to size.

2. Wind on glass spools.

3. Soak in chromic acid solution, 5 gr. to 1 pint water, 3 to 6 hours, according to size.

4. Dry in sun 3 days.

5. Boil in 95 per cent. alcohol 1 hour, under 15 pounds pressure, in autoclave.

Use Mason fruit jars. Do not screw the top down when in sterilizer.

TO STERILIZE LINEN THREAD.

Wind several yards of thread into coils. Boil for 30 minutes in a 1 per cent. solution of bicarbonate of soda. Wash in fresh cold water, and allow to stand in cold distilled water for 6 hours. Then boil in fresh water for 30 minutes. Place in absolute alcohol for 48 hours, then in a solution of Schering’s celloidin with equal parts of alcohol and ether. The mixture must stand for 12 hours, or until dissolved; keep tightly corked. When ready for use add 1 per cent. of sterile oleum ricini, and immerse thread for 48 hours. Then wind upon a frame to dry. This will require from 1 to 3 days. When dry, cut into lengths and coil or wind on glass slides. Boil for 1 hour in normal salt solution. Preserve in Chinesol solution, 1: 500.

=To Sterilize Glycerin or Any Kind of Oil.=—Place bottle uncorked in a vessel of boiling water for 2 hours.

TO PREPARE RUBBER TUBING.

Place different sizes in a deep dish of water. Add bicarbonate of soda to make a 10 per cent. solution. Let come to a boil over a slow fire, then with a stiff brush or cloth rub each piece well. This removes all sulphur, leaving a black surface. Rinse several times, then boil in clean water 15 minutes. Boil 15 minutes before immediate use.

TO PREPARE SIX YARDS OF IODOFORM GAUZE.

Prepare the following solution:

Sterile iodoform, ℥iij; Sterile glycerin, ℥iij.

Mix thoroughly, gradually add alcohol (95 per cent.), f℥iij, then very quickly, ether, f℥vij. Have gauze ready in desired lengths, and drop into solution. Press gauze uniformly to preserve evenness of color. Work rapidly. Prepare table, hands, and person as for an operation. Roll strips, and place in sterile glass jars.

TO PREPARE IODOFORM GAUZE (GREEN-SOAP METHOD).

To saturated boric-acid solution Oj, add green soap to make a good suds. Boil half an hour. To this add iodoform ℥j, then boil 15 minutes. When cool add carbolic acid (95 per cent.) ʒj, stir solution, dip gauze, and roll in strips. Keep in sterile glass jars.

Castile soap is a good substitute for green soap.

IODOFORM EMULSION.

I. Nine parts sterile glycerin in 1 part of iodoform. Dissolve powder for eight hours in bichlorid solution (1: 500). Pour off solution and break up the iodoform after having rinsed it thoroughly in sterile water. Then mix with glycerin.

II. Iodoform, ℥j; sterile glycerin, ℥ix. Put the iodoform in a sterile basin. With a sterile spoon stir in glycerin, a few drops at a time, until a smooth paste has been made. Then add remainder of glycerin.

TO PREPARE PROTECTIVE STRIPS.

Scrub with green soap and rinse well in sterile water. Cut into strips. Disinfect in bichlorid (1: 500) for twenty-four hours. Keep in sterile water three hours. Then place in boric-acid solution. Put in normal salt solution when preparing for immediate use.

TO PREPARE TINCTURE OF GREEN SOAP.

Green soap, 3 parts; Alcohol, 95 per cent., 2 “ ; Ether, 1 part.

To prepare by cold process: Mix ingredients in a pitcher and stir briskly for a few minutes every hour until a solution is formed.

To prepare by warm process: Melt the soap over a slow fire; then remove it to a cool place and stir occasionally. Before it hardens add solutions and mix thoroughly.

Caution: Prepare where there is no danger of the ether igniting.

STERILIZING HAND-BRUSHES.

1. Clean with green soap and water; rinse thoroughly.

2. Place in saturated oxalic solution for 30 minutes.

3. Place in sterile water 30 minutes.

4. Change water twice.

5. Keep dry.

TO PREPARE A PATIENT FOR A SURGICAL OPERATION.

The preliminary preparations are of the _greatest importance_. The usual standing orders should be followed only when no directions have been given by the surgeon. When express directions for preparation are given by the surgeon, the usual standing orders must be disregarded. Caution in the use of cathartics can not be too strongly emphasized, for even a simple laxative at such a time may cost the patient’s life.

The usual standing orders are: For the previous day, liquid diet only. Give a cathartic, a bath, and a hair-wash during the afternoon, and flush the bowels thoroughly a few hours later. Surgical preparations should be completed before retiring time for the night.

Have room and all preparations ready before disturbing patient. Keep patient covered as much as possible. Protect table with a Kelly pad or a good substitute for same. Have at hand a drainage-pan and a bucket.

Shave field of operation.

Scrub with tincture of green soap and rinse with sterile water; then cleanse with ether, followed by alcohol, 70 per cent.

Put on dry sterile dressing (a towel), apply a suitable bandage and fasten securely.

Douches are given only by direction of the surgeon—sterile water preferred.

The final preparation is given in the operating-room a few minutes before the operation is begun, consisting of a heavy coating of tincture of iodin, applied by the surgeon in attendance.

=Morning of Operation.=—Have a specimen of urine ready for analysis. No food six hours before operation. If patient cannot urinate a few minutes before going to the operating-room, catheterize, with doctor’s permission. Remove false teeth, jewelry, and protect patient from the cold.

TO PREPARE A ROOM FOR A MAJOR OPERATION.

BY EVELEEN HARRISON, Graduate of the Post-Graduate Hospital, New York.

_From the American Journal of Nursing._

Of necessity this is far more extensive than the requirement of a minor operation, and should be commenced the day before if possible.

The selection of the room comes first, and as an abundance of clear light is more essential than anything else in an operating-room, let the choice of the room depend on that. When possible avoid using a room into which the sun will shine directly during the time of the operation; but in any case, take the room that gives the most light.

When the house is large enough to allow it, and your choice is not limited, use a room adjoining, or at least on the same floor as the one to be occupied afterward by the patient, and as near the bath-room as possible.

Sometimes it is necessary to use your patient’s bedroom, in which case the bed, after being prepared, should be pushed up in a corner out of the way.

All the furniture that it is possible to remove is taken out of the room; any large piece that has to remain should be covered completely with sheets fresh from the laundry. Carpets and curtains must be removed, _unless the surgeon prefers to have them covered with moist sheets_, and the room thoroughly cleaned, floor scrubbed, windows washed, etc.

As the surgeon will need all the light you can give him, cover only the lower panes of the window with thin muslin curtains, cheese-cloth, or—what will answer the purpose equally as well and is ready at hand—a thick lather of soap rubbed all over the panes and allowed to dry, thus shutting off the gaze of outsiders without excluding valuable light.

The temperature should be about 75° F. and the room well aired beforehand, as no window will be opened during the operation.

A list of articles usually required for a major operation is as follows:

Bandages. One strong kitchen table. Four small tables. Three common chairs. One fountain syringe. Three large basins and pitchers. One small basin and pitcher. One piece of rubber sheeting for table. Two slop-jars or foot-tubs. One gallon of hot boiled water. One gallon of cold boiled water, and always keep a kettle of water boiling on the stove. Antiseptic solutions as ordered. Alcohol. Safety-pins. Green or synol soap. Absorbent cotton. Sterilized gauze. New wooden nail-brush. Two dozen towels, and plenty of clean soft cloths.

This list is an outline of the articles usually required; the surgeon will supplement what is necessary for each particular operation, but when a nurse is called upon to prepare for an operation in a private house, where the conveniences of the hospital are not at hand, she will be thankful to have ready a list of the things that are indispensable. I well remember my first operation outside the hospital, and how difficult I found it to construct a modern operating-room from the limitations of a small country house.

All supplies, when possible, should be on hand the night before the operation, and the room cleaned ready for work.

Facing the best light, and about five or six feet from the window, place the kitchen table, and cover it with a double blanket or comfortable, rubber sheeting, and a sheet fresh from the laundry, the whole pinned firmly at the four corners with safety-pins. Lay on the top a small single sheet, a blanket, and very small, firm pillow.

The little tables are to be arranged around the large one, leaving plenty of room to walk between. Cover them with sterilized sheets; if they have polished tops, first put on a piece of oilcloth or rubber sheeting to prevent damage. These tables are for the instruments, gauze, sponges, sterilized towels, and basin of solution for the surgeon’s hands.