Chapter 23

APPLIANCES AND METHODS FOR THE SICK-ROOM

Patients who are confined to bed even for a few days often suffer acutely from muscular tension, from pressure, and from fatigue due to lack of exercise. Indeed, many a sick person is surprised to find that the bed which had seemed so infinitely desirable can change into a place of torment after a few short days of illness. "Bed-weariness" is hard to bear in any case of illness, but it is doubly hard for persons who are really helpless.

Unless the patient is an experienced sufferer he often has no idea what should be done to make him comfortable; while an equally inexperienced helper, though full of good will, is often discouraged to find that the arrangement she had thought perfect soon fails to satisfy her restless patient. But if she is willing to devote thought and ingenuity to removing small annoyances, she can do many things to alleviate his misery.

BED SORES, or pressure sores, are caused by continued pressure upon the skin. The weight of the body, or of a part of the body, if it comes for a long time upon one place finally interferes with the circulation in the tissues on which the part rests, and consequently interferes with the nutrition of the affected part. Any tissue to which the blood is not bringing all its necessary food supply tends to lose its tone, to become weak, and if the condition persists, to break down altogether.

The direct cause of bed sores then is pressure, and pressure is aggravated by moisture, wrinkles in the bed clothes, crumbs or other hard particles, lack of cleanliness, friction of any kind, or by rough, careless handling. Bed sores occur most often over bony prominences, such as the end of the spine, elbows, heels, shoulders, hips, ankles, and knees, but they may form anywhere, even on the ears or back of the head. They are more likely to appear on thin, aged, or depleted patients. These painful and serious sores can be prevented almost always by faithful care. When they occur, they result in the great majority of cases purely from negligence, and a person who knows the danger and yet through carelessness allows one to develop upon a patient may justly feel herself disgraced.

Prevention of bed sores depends upon keeping the skin dry and clean and upon relieving pressure by special devices and by turning the patient frequently. The parts where pressure comes should be washed at least twice daily with warm water and soap, rubbed frequently with alcohol to improve the circulation and to keep up the tone of the skin, and powdered with a little good toilet powder. Much powder is likely to do harm by collecting in hard, irritating particles. The bed should be kept constantly dry and smooth, and free from crumbs, lumps, wrinkles, or other inequalities. Prolonged pressure should be relieved by turning the patient often,--once every waking hour is not too often if the body is emaciated,--and by pillows, pads, and rings.

Small pillows or thick pads of cotton should be placed under the patient's back and shoulders, between the knees and ankles when he lies on his side, and in other places where sores are likely to develop. Rubber rings are useful, but few patients like them for a long time. They should not be inflated more than necessary to raise the affected part from the bed; if much inflated, they are uncomfortable and may do harm. The ring may be covered with a muslin pillow case, or it may be wound smoothly with long strips of bandage or old muslin. Ordinary cotton batting wound with strips of muslin may be made into rings and used to remove pressure from heels, elbows, or other parts. These cotton rings are less heating than pads, and give better support.

The first sign of a bed sore is either redness of the skin or a dark discoloration like a bruise. Every point where a bed sore may form should be inspected daily. If the slightest symptom of a sore appears, the patient must not lie on the affected part, and every effort should be made to keep the skin from breaking; vigorous rubbing at this stage is dangerous, and will by no means make up for previous neglect. The condition should be reported to the doctor at once. If in spite of all efforts the skin does break, a peculiarly difficult kind of open wound results which must be treated and dressed according to the doctor's directions.

DEVICES TO GIVE SUPPORT.--The variety and number of pillows one patient can use is almost unlimited. A weak patient when lying on his side should have his back supported by a pillow. When he lies on his back a pillow should be placed under his knees to lessen muscular tension, and if he may be raised in bed, several pillows are needed to support him comfortably. A back rest is useful for a patient who can sit up in bed. Satisfactory back rests of several types can be purchased, or one may be improvised from a straight chair placed on the bed bottom side up, so that its legs lie against the head of the bed and its back forms an inclined plane. Back rest and chair alike should be covered by several pillows to make them comfortable, and other pillows should be used to support the patient's arms.

A person who is sitting up in bed always tends to slip down toward the foot. This tendency may be corrected by using a foot rest, knee pad, or pillow. A hard pillow may be placed in the bed at the foot for the patient to brace his feet against; or a short board, well padded, may be arranged as follows for the feet to rest against: Fasten ropes to the board, as the ropes of a swing are fastened to the seat; set the padded board on edge at a convenient point below the patient's feet, and hold it in place by tying the ropes of the "swing" to the head of the bed. A pillow may be used in the same way, either at the feet or under the knees, by folding it over a long strip of muslin, the ends of which are then tied to the sides of the bed, brought up to the head, and there tied to prevent slipping. A cylindrical cushion six or eight inches in diameter and as long as an ordinary pillow, stuffed with firm material, may also be used for this purpose. It should be held in place by strips of strong muslin or ticking sewed to the ends of the cushion and tied to the head of the bed. The cushion should have a washable cover.

Supports called _bed cradles_ are used to keep the weight of the bed covers from sensitive parts of the body, generally the feet or abdomen. They are semi-circular pieces of wood or iron fastened together so that they will stand up. A satisfactory cradle may be improvised as follows: Cut a barrel hoop in two, cross the halves at right angles and tie them together firmly; place the cradle over the affected part under the bed clothes. A smaller cradle may be made by taking sections that are less than half of the barrel hoop. If used for one foot only, the cradle should be small enough not to interfere with the motion of the other foot; if used for both feet, it should be large enough to allow some freedom of motion. Since the cradle leaves an air space, the feet should be wrapped in a piece of soft flannel. A cradle used for the protection of the abdomen should extend a little beyond the body on each side.

Adjustable tables are convenient for patients who are able to sit up in bed. These tables are supported on one side only so that they may extend over the bed. Another kind of bedside table has short legs and stands directly on the bed. Such a table can easily be made at home from a wide board with supports six or eight inches high nailed to each end. A lap board supported by heavy books may serve for temporary use. Indeed, home-made substitutes are often as good as expensive apparatus or even better. If sick-room appliances must be bought, it is well to remember that simple standard designs are best. Complicated apparatus is soon out of order, and is generally a trial both to the patient and to those who must adjust it. Persons taking care of chronic patients may often obtain valuable suggestions in regard to appliances by consulting a visiting nurse or the superintendent of the local hospital.

BEDPANS are utensils to receive bowel and bladder discharges of patients lying in bed. Enamel bedpans are better than porcelain, although more expensive. The shape known as the "Perfection" is best for general use. A "slipper" bedpan, although harder to clean and ordinarily less comfortable, may be preferable if it is especially difficult or undesirable to raise the patient. The square or douche pan is preferred by some people, and is especially useful when the quantity of discharge is large, as after an injection.

When a patient asks for the bedpan it should be brought if possible without a moment's delay, not only because no other form of neglect makes a patient realize her helplessness more acutely, but also because the desire to use it often passes quickly and delay may encourage the habit of constipation. If the patient does not ask for the bedpan, the attendant should offer it at suitable times. Bedpans should be warmed before use. An easy way to warm one is to let hot water run over it; the outside should afterward be dried.

To place the bedpan, first flex the patient's knees and push the night gown up; place one hand under the patient's hips, raise them slightly, and with the other hand slip the pan into place. If the patient is entirely helpless two persons are needed to lift her. Place a pad or folded cloth between the patient's back and the pan; then lower the patient gently. Before removing the pan, bring toilet paper, water and two pieces of soft old muslin or gauze. A patient, if able, prefers to use the toilet paper without assistance; her hands should afterward be thoroughly washed. If she is unable, the attendant must do everything needed. After the patient has been cleaned as thoroughly as possible with paper raise her hips with one hand and then remove the pan; it is important to raise her first because the skin often adheres and may be injured if the pan is suddenly pulled away; carelessness in managing the bedpan has caused more than one bed sore. Then remove the pan with one hand and cover at once. Turn the patient, if helpless, on her side, wash the parts with one piece of old muslin, thoroughly dry them with the other, and either burn or thoroughly wash both pieces afterward.

Empty the bedpan and clean it at once; ordinarily one can clean it without wetting or soiling the hands. Use cold water first, removing all adhering solid particles with a tightly rolled piece of toilet paper. Do not use a brush for this purpose. After using cold water, rinse the pan thoroughly in hot water, and at least once a day wash it well in hot soapsuds. Directions for disinfecting the pan will be given later, but remember that a properly kept pan needs no deodorant solution. Glass urinals should be provided for men, and kept clean in the same way. Contents of both bedpan and urinal should always be carefully inspected; neither should be emptied in the dark.

DAILY ROUTINE IN THE SICK-ROOM

Obviously the routine of a patient's day must vary according to her condition, her preferences, and the amount of time the attendant has to give her. The temperature, pulse, and respiration must be taken and all medicine, nourishment, and treatment given at the exact times ordered, but the attendant should learn whether or not the doctor wishes her to wake the patient for food or treatment. Good management in the sick-room depends upon foresight and planning, and therefore it is well to keep in mind the following suggestions:

Vitality is lowest in the early morning, hence baths and treatments, especially if they are fatiguing or painful, should if possible be left until after breakfast. Patients often wake early and wait, weak and miserable, for the day to begin. A hot drink at this time may give relief and enable the patient to sleep again. Even though breakfast time is near, nourishment should be given as soon as the patient wakes. She may not admit that she is hungry, but her nourishment should not be delayed until the family breakfast is ready, or still worse, finished.

Before breakfast the bedpan should be offered, the patient's face and hands should be washed, her teeth brushed, her hair tidied, the bed straightened, and the room put in order. These services should require a few minutes only. The room if properly arranged at bed time needs only a little attention now unless untidy work has gone on during the night; disorder in a sick-room is as unnecessary in the early morning as at any other time.

After the patient has finished her breakfast she may rest, or if allowed, read her mail or the newspaper while the attendant prepares for her day's work; about an hour after breakfast the patient should be bathed, unless she prefers her bath in the evening. After the bath some form of light nourishment should be given, even to a patient who has regular meals. If a patient is able to sit up in a chair, the best time for her to do so is generally just after the bath and toilet have been completed; but if she feels tired she had better wait until afternoon. The bed room can be better aired and cleaned if it is possible to take her into another room; and she herself generally profits by a change of scene.

The doctor should definitely state when and for how long a patient may sit up for the first time after an illness, and an amateur who may be ignorant of the dangers involved should not assume the responsibility of deciding. When a patient is to sit up for the first time, put on her stockings, slippers, and wrapper before she leaves the bed. Arrange an arm chair with pillows in the seat and at the back, bring it close to the bedside and cover it with a large blanket unfolded. The chair may face either the head or the foot of the bed. Help the patient to a sitting position on the extreme edge of the bed, with her feet hanging down. Next, standing in front of her and supporting her well, let her slip down until she stands upon her feet, then let her turn, and gently lower her into the chair. See that the patient while sitting up is warmly covered, and that her foot-stool, pillows, etc., are adjusted comfortably. Move her chair so that the outlook may be as interesting as possible, and at least a little different from the view from the bed. Most patients like to look out of the window; children and old people enjoy it particularly.

If the patient shows signs of fatigue, she should go back to bed even before the appointed time. To help her back to bed, reverse the process of helping her out. A footstool may be needed if the bed is high, or two people to lift her if she is weak or heavy. When a patient is in bed no one should ever sit on the bed, lean against it, use it as a table for folding linen, making pads, etc., take hold of the bed posts in passing, or touch the bed unnecessarily in any way.

The best time for visitors is the last of the morning or the early afternoon. A judicious visitor may do an immense amount of good, especially to a chronic patient; indeed, she may be the only ray of light in a dark day. Subjects of conversation should be pleasant, but not too stimulating or exciting. The visitor should be prepared to carry the burden of the conversation, to drop topics skillfully that seem to involve fatigue or excitement, and either to go or to stop talking if the patient seems tired. Visitors should remember to talk naturally and cheerfully on ordinary topics, and to avoid excessive sympathy and labored attempts to cheer the patient. They should also remember that few patients bear well even the mildest forms of teasing. The patient's room is not the place to discuss personal or family troubles; yet it is only too often chosen for such purposes, probably because the complainer knows that in it an audience is always to be found.

Visitors not belonging to the family should not be present in the sick-room during treatment of any kind, unless their help is required; neither, as a rule, should they stay during the patient's meals. A member of the family may stay with advantage if the patient tires of eating alone, but casual visitors almost invariably offend by undue urging if the patient's appetite is poor, or by facetious remarks if it is good.

Ordinarily only one visitor should be admitted at a time, since a weak patient may be tired merely by looking from one to another. If it is desirable to limit the call, the attendant should tell the visitor beforehand how long to stay, or arrange a signal for the visit to end. To announce baldly in the sick-room that the patient is tired and the visitor must go, will only elicit aggrieved protests from both. In illness lasting only a day or two all visitors should be discouraged; during colds, because they are communicable; during general fatigue, headaches, digestive upsets, and painful menstruation, because rest and quiet are highly desirable. Visitors at such times too frequently give injudicious sympathy, and may actually delay the recovery of patients who enjoy playing the rôle of interesting invalid.

The time when a trustworthy visitor is present may be the best time for the attendant to rest. The patient should be told when the attendant is going, and approximately when she will return. It is a mistake to slip away while the patient sleeps; she seldom fails to wake before the time scheduled and to resent the desertion. Surprises of any kind, pleasant or unpleasant, are seldom good for patients.

Toward the end of the afternoon the patient is probably tired, especially if she has not slept during the day. When fever is present her headache and restlessness increase as the day goes on, but it should be remembered that uncomfortable beds and too heavy covers cause much of the restlessness attributed to fever. Rubbing the back and legs with alcohol, giving a tepid sponge bath, remaking the bed or changing her position may help to soothe her.

The evening should be kept free from excitement, and every possible effort should be made to encourage sleep. It is a mistake to think that a better night results from keeping a sleepy patient awake all the evening; sick people should sleep when they can. Just before bedtime the attendant should prepare her own cot, and then make the following preparations for the patient to sleep: wash the patient's face and hands or give a sponge bath if it is desired, brush the hair, change the night gown, brush crumbs from the bed, tighten the sheets or remake the bed if necessary, rub the back and other pressure points with alcohol, shake the pillows, give liquid nourishment, preferably hot, cleanse the mouth, and give the bedpan. See that the patient's feet are warm, the bed covers right, the room ventilated properly and in good order, and the light extinguished or arranged for the night. If the patient is inclined to be wakeful a hot foot bath may help her, or sponging the entire length of the spine for fifteen minutes, using very hot water and long downward quiet strokes. No conversation should be encouraged during preparations for the night. Patients in bed all day often lose the habit of sleeping at the regular time, and lie awake far into the night from a vague feeling that someone else is coming or something further is to be done for them. Consequently last of all ask the patient if she wants anything more; if not, say good-night, go out and stay out, at least until she has had a chance to go to sleep. She is thus helped to realize that nothing further is likely to happen, and that it is time to go to sleep.

Toward morning the patient grows weaker. More bed covers will probably be needed, and they may often be added without waking her. Night at the best is a dreary time for the sick. Pain and weariness and discouragement are less bearable in the darkness; nervous fears and morbid fancies defy control. Never is kindness more needed or more appreciated than it is by those who lie awake and watch for the morning.

EXERCISES

1. Name all the causes, direct and indirect, of pressure sores.

2. Why are pressure sores generally more serious than injuries of equal extent to the skin of a well person?

3. Where are pressure sores most likely to occur and what are their symptoms?

4. What measures should be employed to prevent pressure sores?

5. Describe ways to support a person lying down in bed.

6. Describe ways to support a person sitting up in bed.

7. How may the weight of the bedclothes be removed from any particular part of the body?

8. How should a bedpan be cared for?

9. Describe in detail a day's routine either of yourself the last time you were ill in bed, or of another patient personally known to you. Could the plan of the day have been improved, and if so, in what ways?