CHAPTER V.

DUTIES OF THE NURSE IN VARIOUS CIRCUMSTANCES, CONTAGION, DEATH, &C.

The fact that certain diseases are contagious is one that throws some grave responsibilities upon the nurse, and on account of the importance of the subject, I will here discuss it in the light of modern science.

Infectious diseases are supposed to be propagated by the agency of minute living parasites given off from the body of the sick and conveying the specific virus. The germ thereby includes this for the cause of all the zymotic diseases—diseases that are contagious and produced by some morbid principle or germs acting on the system like a ferment. They are claimed to be a vegetable growth of a fungoid nature, and the theory is that during the process or period of each—a period of growth like mildew—the victim is a sufferer from a more or less violent fever; that the period varies; in typhoid it is twenty-one days, in other forms of fever perhaps a shorter time, till the microscopic fungoid growth may be said to effloresce and shed its spores. Some diseases also that are not contagious are believed to be caused by organisms in the air. There are various kinds; monads, bacteria, vibriones, &c., are among the substances found in the atmosphere of a large city, and elsewhere.

A very great variety of these forms called fungoid growth have been seen and distinguished, and it is demonstrated clearly that certain forms cause certain diseases. For example, cholera or choleraic symptoms have been induced in animals by the introduction of the cholera bacillus into their intestines, and almost invariably the dead animals showed a great abundance of the characteristic bacillus in the intestinal tract. The diseases which are now known or believed to be caused by such virus are very numerous, and directions for preventing a disease from spreading are based upon this theory; epidemic and endemic diseases are generally attributed to such a cause. The list of germ diseases is about as extensive as the list of contagious diseases.

EPIDEMIC DISEASES are those that act upon numbers of people at the same time. Probably there is generally, though not always, disease organisms diffused through the air.

ENDEMIC DISEASES are confined to particular localities. Sporadic cases of disease are those occurring singly, or scattered considerably.

DISINFECTANTS are such substances as act upon the specific germs or minute living particles to destroy them. ANTISEPTICS are such as prevent decomposition or putrefaction.

SEPTIC GERMS are generally destroyed when widely diffused in the air. It is believed that oxygen acts as a disinfectant, at least dry air is not favorable to their growth. A dry heat of 300 degrees will destroy them, and they are generally killed by a freezing temperature. Against communicable diseases the chlorine class of antiseptics including iodine, iodoform, bromine, and sulphur are the most effectual, and chlorine and sulphuric acid may without danger be used in the sick room to a sufficient extent to do some good.

The most rapid and powerful of the disinfectants is the solution of the bichloride of mercury (corrosive sublimate). The solution most commonly used is of the strength of fifteen grains to the quart. It can be applied directly to floors, beds, walls, sinks, drains, vessels, &c.

For clothing use a solution of common salt and sulphate of zinc, two ounces of the salt and four ounces of the sulphate to a gallon of hot water; soak the clothes in this and then boil them in water with borax, or soap or soda.

When a disease is known to be very contagious and dangerous, especial care is necessary to avoid contact on the part of patients and nurses with outsiders. All superfluous things must be taken out of the room before the patient is put into it, and care will be necessary continually to make the quarantine effectual. Every article carried out of the sick room must be disinfected; a set of dishes should be kept for the patient’s exclusive use, washed only by the nurse; the bedding, clothing, &c., must be washed by the nurses themselves, after being soaked in a disinfecting solution; dressings and other cloths, such as old cloths used for handkerchiefs, may be burned; all excrementitious and vomited matter must be disinfected; the broom that is used to sweep the room must not be used elsewhere; no current of air must be permitted to pass from the sick room to the rest of the house; and it is well also to hang about the room cloths wet with some disinfectant solution; hang over the doorway a sheet similarly disinfected; and the nurse should cover her head with a close cap.

Lest the confinement and isolation make the nurse sick she must take care of her own health. Two nurses should be employed for every such case, so that neither may be obliged to sleep in the same room with the patient, and each should change her clothes and go out of doors for a time every day and take a brisk walk in the open air.

The ventilation is of especial importance in contagious diseases, as no disinfection can render the air entirely pure. To prevent the infectious particles that are thrown off the skin in cases like small pox and scarlet fever, from polluting the air of the room, the clothes should be frequently changed, and the patient’s body be washed and anointed with some ointment.

Charcoal placed about the room in shallow vessels does some good by means of its property of absorbing gas; and solutions of carbolic acid, chloride of lime, soda, and zinc are germicides, but the chief use of the carbolic acid family is where suppuration is going on, to prevent the spread of septic infection. It is also a means of disinfection perhaps, if the spray is used in malarial disease. Condy’s fluid and sulphate of iron are used as antiseptics, but these stain clothing.

Chlorine should not be used with sulphuric acid, or carbolic acid.

Either copperas or chloride of lime may be thrown dry into water closets. A little disinfectant should be kept standing in all sputa cups, urinals, and bedpans, and in cases of typhoid, and cholera, the stools must be carefully disinfected. These diseases are not only directly infectious, but the germs in the discharges may multiply and spread the disease. Cover the bottom of receiving vessels for stools with copperas or chloride of lime, and after use add crude hydrochloric or sulphuric acids in quantity equal to half the bulk of the discharge. Cover closely and carry from the room, and empty into a trench prepared to receive them, at a distance from the water supply, and all clothing and bedding soiled by the discharges must be disinfected and boiled.

After a case is ended the room must be subjected to a cleaning and fumigation. Everything that can be so treated should be either boiled or subjected to a heat of 220° in a disinfecting oven. Rubber sheets and aprons may be cleaned with bichloride solution, and the floors, woodwork, and perhaps the walls should also be washed with a solution of bichloride of Mercury. While the room is being fumigated, drawers and closets should be open and things not thoroughly disinfected should be hung up in it. A good way to fumigate the room is to burn sulphur in it, but you may evolve chlorine from common salt in the following way: Mix an equal bulk of common salt and black oxide of manganese in a shallow earthen dish, add two pints of sulphuric acid previously diluted with two pints of water, and stir with a stick. It is best in using this to have also steam in the room.

To fumigate a room have the doors, windows, and fireplace closed, and paste paper carefully over the cracks. If sulphur is used put it in iron pans, allowing two pounds to every thousand cubic feet of space; set the pans on brick, so that they will not burn the floor; pour a little alcohol on the sulphur and ignite, then leave the room quickly so that you do not breathe the gas; paste up the door when you go out; keep it closed for twenty-four hours, then open all the windows and let the room air.

Those directing the disinfection should always remember the bleaching and corroding power of chlorine and sulphurous acid gas.

When a patient has died from any infectious disease the body should be washed in some disinfectant solution, or soap should be used containing bichloride of mercury, and a sheet should be wrapped around the body wet with the same. Saturate also a large wad of cotton with it and leave it under the hips. The burial should be soon and private in these cases.

OF THE NURSE’S DUTIES IN CARING FOR THE DYING AND DEAD.

Certain duties devolve upon the nurse in cases of DEATH from any disease, and I prefer to refer to those duties here.

Among the signs that indicate approaching dissolution are a peculiar sharpness of the features; coldness of the toes, fingers and nose; a dusky shade about the finger nails; cold perspiration, restlessness, and muscular twitchings or stupor. When you are sure that the end is near it is best that the friends should be informed. While there is slight grounds for hope do not give up all efforts, but do not disturb the dying by useless ministrations. Note the exact time at which death takes place; this is usually, though not always, obvious.

There may be a rise of temperature, and the body be quite warm a short time after death; this is produced by chemical changes, but after a short time its temperature corresponds with that of the room in which it is lying. Then the peculiar stiffening of the muscles called RIGOR MORTIS sets in which lasts for a time and then disappears. Before rigor mortis comes on prepare the body for burial by washing it (using a weak solution of chlorinated soda or carbolic acid), closing the eyes, arranging the lips naturally, and combing the hair. Bandage the jaws closely, stuff all the orifices of the body with absorbent cotton to prevent discharges, and bind a cloth around the hips. A clean night dress or shroud or any other clothing desired can be over this, then cover the face and all with a sheet.

The arrangements can be put in the hands of an undertaker, but it is quite likely the friends will wish you to superintend them. If the body is to be kept for several days it must be packed in ice, and after twenty-four hours the face has a more natural appearance. The dark discoloration of the skin observable a few hours after death on the neck and sides and more dependent parts, is caused not by mortification, but by the blood settling or gravitating downwards. Slight discolorations about the face can be made less conspicuous by dusting them with toilet powder.

After the body has been taken from the house, the bedding must be sent out to be disinfected, all the appliances of sickness removed, the room put in order, and the windows left wide open for several hours.

SOME GENERAL LESSONS IN NURSING.

Rule 1. Do not get out of temper, but try to make the sick chamber the pleasantest and yet the quietest room in the house. Do not appear anxious however great your anxiety.

2. Do not converse in whispers; invalids generally are suspicious and will imagine all sorts of things if they see their friends conversing in this manner.

3. Do not urge the invalid to eat and drink when she does not feel like it.

4. Do not ask a convalescent if she would like this or that to eat and drink, but prepare the delicacies and present them in a tempting way.

5. Do not allow the nauseating medicine bottles to stand in the sight of the patient.

6. Study all the peculiarities of your patients, and instead of opposing them by arguments or otherwise, humor them whenever they do not interfere with the physician’s orders or instructions.

7. In all cases keep everything that is used by the patient perfectly clean.

8. If the patient is not allowed to drink as much as she desires, give her the limited quantity instead of a full glass. If she is allowed to drain the glass she will probably be satisfied.

9. Do not allow flowers or plants to remain in the room over night, and always remove flowers from the sick chamber as soon as they become stale.

10. In all cases the patient should have baths so often that the skin is kept clean, and the pores are not stopped up.

11. Take care not to chill or fatigue a patient while bathing. A sponge bath can be given in bed, the bed being protected by an extra draw sheet.

12. The mouth should be often washed and the teeth brushed or wiped off with a soft cloth.

13. The hair should be combed at least once daily. The ladies’ hair is braided or twisted on top of the head so that she will not have to lie on a knot.

14. Do not light a sick room at night by means of a jet of gas burning low.

15. Preferably use sperm candles.

16. Do not have the temperature of the sick room much above 60°.

17. Do not allow offensive matters to remain; but in a case of emergency where these cannot be removed at once, you can wring a heavy cloth out of cold water and use as a cover, placing over this ordinary paper.

18. Do not neglect during the day to attend to necessaries for the night, that the rest of the patient and family be not disturbed.

19. To avoid making a noise by throwing coals on the fire, place it in paper bags and lay them on the fire.

20. Do not lean or sit upon the bed, if this is disagreeable to the patient.

21. Always remember that nothing which contributes to the welfare of those who require the nurse’s care, is too trivial to demand her attention.

22. The following may by some be called little matters, but attention to them will add materially to the well being of the sick: Refrain from constant enquiries of patients as to how they feel, for sick people are easily annoyed; anticipate the wants of your patient if possible; never tiptoe about the room; if the patient is very sick have the courage to tell the friends who call that the invalid cannot see friends, if able to see them their stay must not be prolonged; do not allow a patient to sit up in bed without covering the shoulders with some light wrap; support them properly with pillows, or a chair and pillows; when obliged to leave the room take something with you which is no longer needed, and bring back necessary articles, thus saving annoyance to the patient and labor to yourself.

23. To AVOID MISTAKES IN GIVING MEDICINE it is a good rule to always read the label before and after measuring the dose; no medicine should ever be given in the dark; tie a ribbon on bottles that contain remedies for external use; shake a bottle before opening it; do not leave a bottle uncorked; generally keep medicines in a dark closet which is cool as possible; have every medicine that is dangerous taken internally labeled “poison”; keep them under lock and key.

24. The nurse should know the ordinary doses of medicines and the symptoms of overdosing. Every unusual and inordinate action of a drug may be a good reason for omitting a dose or two till the physician is seen and new directions are given, otherwise be always regular and prompt in the administration of medicines.

25. But in general the nurse can best display her knowledge and exercise her skill by faithfully carrying out the instructions she has received from the physician. If the directions are not what she would expect, it may be an exceptional case; the doctor and not the nurse is the judge as to what is exceptional; she must obey his orders. Do not receive orders from the physician in silence, and when he is gone refuse to obey them. The nurse should never hide anything from the doctor, even if she has done wrong; it is a serious thing to think that life should be risked in order to conceal wrong doing. Never be afraid of troubling the doctor; he will always be glad to hear anything that will help in the diagnosis or treatment of the case. The nurse has much to do with an art whose end is the saving of human life; any neglect to act openly and intelligently becomes a crime.

26. Remember that kindness and tenderness as well as faithfulness are needful to successful nursing.

BEDSORES.

Every precaution should be taken by the nurse to avoid bedsores on her patient. These appear most frequently upon the hips, but may develop elsewhere in parts subjected to pressure. To harden the parts they must be frequently washed with soap and water and thoroughly dried. A draw sheet should be placed under the patient that can be changed as often as it becomes wet and damp. Be careful to keep the sheet free from wrinkles and inequalities, and the patient’s clothes must be kept smooth under her. Occasionally rub on the skin oil or vaseline, and then dust on some fine powder such as oxide of zinc, fine starch, or toilet powder.

Plasters that are entirely unirritating may be applied either before or after there is an evident sore, and if change of position is not possible, it may be necessary to obtain air cushions or a water bed.

An air mattrass or air cushions may be put on any bed, but a water bed must be put in a trough or wooden frame made of just the right size. The water in a bed of this kind should be of a temperature of 70° and renewed every two weeks. To prevent a water bed from sticking to the boards some old cloths must be interposed.

Reddening and roughening of the skin, and pain on pressure indicate an approaching bedsore before there is an abrasion of the skin. Those washes that cause smarting must be discontinued, and sulphate of zinc ointment, and unirritating plasters used.

If a part is dead and likely to slough off, apply charcoal or yeast or chlorinated poultices until the gangrenous parts can be removed. After the separation of the slough you can apply lint smeared over with carbolated cosmoline or whatever application the surgeon or doctor may direct. The sore must be washed and applications renewed each day, and at each time it may be covered with a piece of oiled silk or muslin, or rubber tissue confined in place by adhesive straps.

BATHS.

The SPONGE BATH or washing can be done partly under the bed clothes, and but a small part of the body need to be exposed at a time. Do not bathe immediately after a meal.

Always have a bath of the temperature directed by the doctor. The following terms are used to indicate different temperatures:

BATH. WATER. VAPOR. AIR.

Cold, 32° to 65° Fahr. Cool, 65 to 75 Temperate, 75 to 85 Tepid, 85 to 92 90° to 100° 96° to 106° Warm, 92 to 98 100 to 115 106 to 120 Hot, 98 to 112 115 to 140 120 to 180

To put a feeble patient in a bath wrap her in a sheet and lower her gently down in it. When she is taken out wrap her in a warm dry sheet and over this fold a blanket. After a few minutes’ rest and a little wiping with a soft dry towel the clothes may be put on.

Do not give a cold bath when the patient feels chilly, when there is perspiration, or there is inflammation or congestion of an internal organ.

The temperature of the body may be lessened by means of the wet pack in cold water, or by means of a sheet wrung out of cold water wrapped around the patient, and changed every ten or fifteen minutes, or by applying towels from the neck downwards, wrung out of cold water.

For the wet pack the sheet may be wrung out of either hot or cold water. Spread a comforter and two blankets on the bed and over these a sheet wrung out of the water. Remove all the patient’s clothing, lay her in the middle of the sheet, then draw over one side after another of the blankets and comforter, wrapping her from the neck to ankles; apply something to the feet to keep them warm, give plenty of drink, and put a wet compress on the forehead. If this is intended to induce perspiration or repose, the patient may remain in the pack two or three hours.

A BLANKET BATH is used as a means of sweating. A blanket is wrung out of hot water and wrapped around the patient. She is to be packed in three or four dry blankets and allowed to rest quietly for thirty minutes. Then the surface of the body must be well rubbed with warm towels, and the patient made comfortable in bed.

COLD OR TEPID SPONGING is sometimes directed when there is a fever. Commence at the head and sponge downwards, then wrap in a blanket and leave her undisturbed for an hour or more.

The effect of the HOT BATH if long continued is to induce languor and weakness. Watch by the patient while she is in the water, and take her out if there is any sign of fainting. Do not give a hot bath during a menstrual period.

A hot foot bath is one of the best means of revulsion to relieve the head. Let the water come nearly to the knees, cover both the patient and tub with a blanket, keep the feet in the hot water for about twenty minutes.

If a HOT AIR BATH or a VAPOR BATH is given, some device should be used to keep the blankets from pressing upon the patient. Two half hoops may be tied together so that they answer the purpose. By the same means steam may be diffused around her, if hot bricks wrapped in wet flannel and put on dishes are placed in the bed beside her, or steam can be conducted from a boiling teakettle under the blankets. Or place the patient in a large cane seated chair, and surround both completely with blankets, letting them extend to the floor and be secured about the patient’s neck. Under the chair, place a basin of hot water with an alcohol lamp beneath it; bring the water to boiling, and the patient will soon be in a perspiration which may be carried to any extent.

For a BRAN BATH, boil two pounds of bran in a gallon of water and add to the bath.

For a SALT BATH, add one pound rock salt to every four gallons of water.

For a SULPHUR BATH, add twenty grains sulphuret of potassium to a gallon of water. Used for skin diseases and rheumatism.

In cases where there is a high fever, especially in children, the warm water bath is given to reduce the temperature. If a child that has a temperature of 104° is immersed in water heated only to 98° for fifteen or twenty minutes, it will part with some of its heat.

BATHING OF INFANTS.

The bath for very young infants should be quite warm—about 97°. Some nurses ascertain if it is an agreeable warmth by dipping an elbow in the water. The temperature may from week to week be lowered gradually to 85° or 80°. Two baths a day may be given. The evening bath should be warmer than the morning. A brisk, gentle rubbing after the bath is beneficial. If a child gets blue and shivers the bath is too cold. The warm bath will often serve to put a restless and feverish child to sleep.

To bathe an infant support its head on your hand and arm, dip the baby into the bath; then rub the whole surface of the skin rapidly with a soft sponge or piece of flannel soaped; next again immerse the body in the water, then quickly and thoroughly dry with a fine warm towel.

Before giving a bath have every thing likely to be needed at hand, and the room warm.

CHANGING CLOTHING.

Before raising up a patient to put on a chemise or night dress, pull up the soiled one towards the neck, and as soon as the head and shoulders are raised, the soiled garment can be slipped off over the head and a clean one put on; then pull this down smoothly under the back before laying the patient down.

If two garments are worn one can be slipped inside the other, and they can be slipped on as one.